Provider Demographics
NPI:1760756639
Name:TALAG, MARITA ECALDRE (PT)
Entity Type:Individual
Prefix:MS
First Name:MARITA
Middle Name:ECALDRE
Last Name:TALAG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922 LUNAR CIR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-6926
Mailing Address - Country:US
Mailing Address - Phone:620-655-9879
Mailing Address - Fax:
Practice Address - Street 1:3290 N RIDGE RD STE 290
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3657
Practice Address - Country:US
Practice Address - Phone:410-750-9006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 25837225100000X
MI5501009944225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist