Provider Demographics
NPI:1336791854
Name:COLLINGWOOD, TARA (RD, CSSD, LDN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:COLLINGWOOD
Suffix:
Gender:F
Credentials:RD, CSSD, LDN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:GIDUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, CSSD, LDN
Mailing Address - Street 1:1161 BANBURY TRL
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4801
Mailing Address - Country:US
Mailing Address - Phone:321-287-8834
Mailing Address - Fax:
Practice Address - Street 1:3000 N ORANGE AVE STE D
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-7613
Practice Address - Country:US
Practice Address - Phone:321-287-8834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
816645133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered