Provider Demographics
NPI:1942534854
Name:VAN GINDERDEUREN, TIARA SOARES (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:TIARA
Middle Name:SOARES
Last Name:VAN GINDERDEUREN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:TIARA
Other - Middle Name:
Other - Last Name:SOARES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:1100 BLYTHE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5814
Mailing Address - Country:US
Mailing Address - Phone:704-355-4645
Mailing Address - Fax:704-355-4231
Practice Address - Street 1:275 BEATY RD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-2603
Practice Address - Country:US
Practice Address - Phone:704-822-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7310225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist