Provider Demographics
NPI:1528782158
Name:TAN, CIARA GRACE MADERAZO
Entity type:Individual
Prefix:
First Name:CIARA GRACE
Middle Name:MADERAZO
Last Name:TAN
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 1:1200 CORPORATE DR STE 400
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35242-5424
Mailing Address - Country:US
Mailing Address - Phone:866-518-0283
Mailing Address - Fax:
Practice Address - Street 1:156 NW CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2492
Practice Address - Country:US
Practice Address - Phone:772-871-7170
Practice Address - Fax:772-871-9330
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2025-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016488225100000X
FLPT42534225100000X
CT011731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist