Provider Demographics
NPI:1477205300
Name:PRUNA, TARA (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:PRUNA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13620 CRYSTAL RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8445
Mailing Address - Country:US
Mailing Address - Phone:954-825-9659
Mailing Address - Fax:
Practice Address - Street 1:1219 DUNN AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2405
Practice Address - Country:US
Practice Address - Phone:386-255-4568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14068092235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty