Provider Demographics
NPI:1881704385
Name:TICOMB, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:TICOMB
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 1:20 OLD HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2828
Mailing Address - Country:US
Mailing Address - Phone:631-839-1470
Mailing Address - Fax:
Practice Address - Street 1:141 DURHAM RD
Practice Address - Street 2:STE 14
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2676
Practice Address - Country:US
Practice Address - Phone:203-245-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000857OtherLICENSE #