Provider Demographics
NPI:1821445685
Name:LIDDLE, TARA JEANNE (PT MA)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:JEANNE
Last Name:LIDDLE
Suffix:
Gender:F
Credentials:PT MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 7TH AVE
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-7247
Mailing Address - Country:US
Mailing Address - Phone:917-865-9984
Mailing Address - Fax:
Practice Address - Street 1:263 7TH AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-7247
Practice Address - Country:US
Practice Address - Phone:917-865-9984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8328-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist