Provider Demographics
NPI:1992840672
Name:VANCIL, TARA BROOK (OT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:BROOK
Last Name:VANCIL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 SHERBURN CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-9017
Mailing Address - Country:US
Mailing Address - Phone:407-810-2773
Mailing Address - Fax:407-867-6203
Practice Address - Street 1:606 SHERBURN CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9017
Practice Address - Country:US
Practice Address - Phone:407-810-2773
Practice Address - Fax:407-867-6203
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC008439225X00000X
FLOT18363225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50063899Medicare UPIN