Provider Demographics
NPI:1881091254
Name:TAFT, COURTNEY (PTA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:TAFT
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 1:1155 MALABAR RD NE STE 1
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-3262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1155 MALABAR ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905
Practice Address - Country:US
Practice Address - Phone:321-409-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA24920225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant