Provider Demographics
NPI:1326572884
Name:DEFORGE, TALIA ANNE
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:ANNE
Last Name:DEFORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 HOSPITALITY DRIVE
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641
Mailing Address - Country:US
Mailing Address - Phone:802-229-0308
Mailing Address - Fax:
Practice Address - Street 1:98 HOSPITALITY DR
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-5360
Practice Address - Country:US
Practice Address - Phone:802-229-0308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT041.0000513225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant