Provider Demographics
NPI:1265738363
Name:TABARE, MAIJERLYNG (PTA)
Entity type:Individual
Prefix:MS
First Name:MAIJERLYNG
Middle Name:
Last Name:TABARE
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 1:15031 SW 42ND TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-4351
Mailing Address - Country:US
Mailing Address - Phone:305-378-5775
Mailing Address - Fax:305-378-5772
Practice Address - Street 1:11005 SW 186TH ST
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-6810
Practice Address - Country:US
Practice Address - Phone:305-378-5775
Practice Address - Fax:305-378-5772
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22511225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant