Provider Demographics
NPI:1790796688
Name:FORMAN TATA, GEORGIANNA (PT)
Entity Type:Individual
Prefix:MRS
First Name:GEORGIANNA
Middle Name:
Last Name:FORMAN TATA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:GEORGIANNA
Other - Middle Name:
Other - Last Name:FORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:219 MATTHEW ST
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1417
Mailing Address - Country:US
Mailing Address - Phone:203-758-4249
Mailing Address - Fax:
Practice Address - Street 1:60 WESTWOOD AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2460
Practice Address - Country:US
Practice Address - Phone:203-597-1609
Practice Address - Fax:203-597-1581
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006595225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist