Provider Demographics
NPI:1811391055
Name:SMITH, TARA NELSON (MS, PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:NELSON
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 DOWNES AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-4065
Mailing Address - Country:US
Mailing Address - Phone:718-702-4232
Mailing Address - Fax:
Practice Address - Street 1:905 ANNADALE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-4010
Practice Address - Country:US
Practice Address - Phone:718-984-5826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist