Provider Demographics
NPI:1376179473
Name:MENDRES, TARA (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MENDRES
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13815 CADEN GLEN DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34669-5021
Mailing Address - Country:US
Mailing Address - Phone:239-810-4661
Mailing Address - Fax:
Practice Address - Street 1:3023 SUNLAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-8155
Practice Address - Country:US
Practice Address - Phone:813-346-1026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL23122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer