Provider Demographics
NPI:1184061418
Name:ABBOTT, TARA LAUREN (DPT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LAUREN
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1392 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-7070
Mailing Address - Country:US
Mailing Address - Phone:909-256-3762
Mailing Address - Fax:909-256-3764
Practice Address - Street 1:1392 W 7TH ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-7070
Practice Address - Country:US
Practice Address - Phone:909-256-3762
Practice Address - Fax:909-256-3764
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 40173225100000X
CA401732251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA110983Medicare PIN
CACA153428Medicare PIN
CACA165824Medicare PIN
CACA110984Medicare PIN