Provider Demographics
NPI:1326226283
Name:BUSH, TARA L (LMT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:BUSH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 CORAL DR SW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-6628
Mailing Address - Country:US
Mailing Address - Phone:850-499-5054
Mailing Address - Fax:
Practice Address - Street 1:193 CORAL DR SW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-6628
Practice Address - Country:US
Practice Address - Phone:850-499-5054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-03
Last Update Date:2008-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA41462225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist