Provider Demographics
NPI:1164707378
Name:TAIT, ANDREA L (PT)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:L
Last Name:TAIT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6311 LAMBERT ST
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-9254
Mailing Address - Country:US
Mailing Address - Phone:585-944-4664
Mailing Address - Fax:
Practice Address - Street 1:953 HIGH ST
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:NY
Practice Address - Zip Code:14564-1168
Practice Address - Country:US
Practice Address - Phone:585-924-3252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0211242251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics