Provider Demographics
NPI:1538793518
Name:ANDRADE, TARA (PT, DPT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ANDRADE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 PINE HALL DR APT 306
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-8113
Mailing Address - Country:US
Mailing Address - Phone:401-241-3565
Mailing Address - Fax:
Practice Address - Street 1:1650 E BOOKER DAIRY RD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-9405
Practice Address - Country:US
Practice Address - Phone:919-938-9088
Practice Address - Fax:919-938-9091
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305213437225100000X
NCP19421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist