Provider Demographics
NPI:1184696916
Name:COLLINS, TARA L (PT,CSCS)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:COLLINS
Suffix:
Gender:M
Credentials:PT,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2889 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06605-3211
Mailing Address - Country:US
Mailing Address - Phone:203-345-1720
Mailing Address - Fax:203-549-0725
Practice Address - Street 1:2889 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-3211
Practice Address - Country:US
Practice Address - Phone:203-345-1720
Practice Address - Fax:203-549-0725
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0040782251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ32951OtherEMPIRE BLUE CROSS
CT080004078OtherBLUE CROSS BLUE SHIELD