Provider Demographics
NPI:1386422020
Name:STEWART, TAEGAN L
Entity type:Individual
Prefix:
First Name:TAEGAN
Middle Name:L
Last Name:STEWART
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 1:9975 TAVISTOCK LAKES BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7665
Mailing Address - Country:US
Mailing Address - Phone:863-676-0174
Mailing Address - Fax:
Practice Address - Street 1:9975 TAVISTOCK LAKES BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7664
Practice Address - Country:US
Practice Address - Phone:863-676-0174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL32778225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant