Provider Demographics
NPI:1457768962
Name:LAURENZI, TARA (LMT, RYT)
Entity type:Individual
Prefix:MISS
First Name:TARA
Middle Name:
Last Name:LAURENZI
Suffix:
Gender:F
Credentials:LMT, RYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1120
Mailing Address - Country:US
Mailing Address - Phone:716-308-4285
Mailing Address - Fax:
Practice Address - Street 1:752 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-1120
Practice Address - Country:US
Practice Address - Phone:716-308-4285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011411-1172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist