Provider Demographics
NPI:1215217666
Name:DONNELLY, TARA (PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:DONNELLY
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 1:96 SILVER OAK CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-4665
Mailing Address - Country:US
Mailing Address - Phone:203-578-0409
Mailing Address - Fax:
Practice Address - Street 1:465 WOLCOTT RD
Practice Address - Street 2:ADVANCED PHYSICAL THERAPY
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2613
Practice Address - Country:US
Practice Address - Phone:203-897-0107
Practice Address - Fax:203-879-0206
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT007482OtherCT LICENSE