Provider Demographics
NPI:1942513593
Name:PANDOS, TARA JANE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:JANE
Last Name:PANDOS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1287 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-2730
Mailing Address - Country:US
Mailing Address - Phone:216-221-6275
Mailing Address - Fax:
Practice Address - Street 1:3366 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44127-1638
Practice Address - Country:US
Practice Address - Phone:216-271-1133
Practice Address - Fax:216-271-1325
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH17633225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist