Provider Demographics
NPI:1669131330
Name:TARDIF, TAYLOR NICOLE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:NICOLE
Last Name:TARDIF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-4923
Mailing Address - Country:US
Mailing Address - Phone:860-584-3400
Mailing Address - Fax:
Practice Address - Street 1:12 WIHBEY DR
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-1226
Practice Address - Country:US
Practice Address - Phone:860-384-2442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2156224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant