Provider Demographics
NPI:1245973106
Name:BRADSTREET, TARA LYNN (PTA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:BRADSTREET
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 ELLIS FALLON LOOP
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5967
Mailing Address - Country:US
Mailing Address - Phone:919-896-4547
Mailing Address - Fax:
Practice Address - Street 1:901 CLARK ST
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7378
Practice Address - Country:US
Practice Address - Phone:407-359-5693
Practice Address - Fax:407-792-5693
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant