Provider Demographics
NPI:1629141064
Name:GARRETT, TARA SUZANNE (MS PT CLT LA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:SUZANNE
Last Name:GARRETT
Suffix:
Gender:F
Credentials:MS PT CLT LA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:705 MAPLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-3291
Mailing Address - Country:US
Mailing Address - Phone:716-805-7360
Mailing Address - Fax:716-580-7396
Practice Address - Street 1:705 MAPLE RD STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3291
Practice Address - Country:US
Practice Address - Phone:716-580-7360
Practice Address - Fax:716-580-7396
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014055-1225100000X
NY014055225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000627413001OtherBLUE CROSS BLUE SHIELD
NY9312131OtherINDEPENDENT HEALTH
NY000627413001OtherBLUE CROSS BLUE SHIELD