Healthcare Provider Details

I. General information

NPI: 1134713332
Provider Name (Legal Business Name): TARA ANGIE DICHIARO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2021
Last Update Date: 02/27/2021
Certification Date: 02/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LABBY RD
NORTH GROSVENORDALE CT
06255-1247
US

IV. Provider business mailing address

113 LABBY RD
NORTH GROSVENORDALE CT
06255-1247
US

V. Phone/Fax

Practice location:
  • Phone: 860-497-0239
  • Fax: 860-497-0047
Mailing address:
  • Phone: 860-497-0239
  • Fax: 860-497-0047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number001537
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: