Provider Demographics
NPI:1508529488
Name:PETERSON, TAJSHMA TAGAYLA
Entity Type:Individual
Prefix:
First Name:TAJSHMA
Middle Name:TAGAYLA
Last Name:PETERSON
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 1:204 PLEASANT GROVE RD
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4414
Mailing Address - Country:US
Mailing Address - Phone:727-667-4993
Mailing Address - Fax:
Practice Address - Street 1:315 NE 10TH AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-4456
Practice Address - Country:US
Practice Address - Phone:352-795-7006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency