Healthcare Provider Details

I. General information

NPI: 1215217666
Provider Name (Legal Business Name): TARA DONNELLY PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 WOLCOTT RD ADVANCED PHYSICAL THERAPY
WOLCOTT CT
06716-2613
US

IV. Provider business mailing address

96 SILVER OAK CIR
SOUTHINGTON CT
06489-4665
US

V. Phone/Fax

Practice location:
  • Phone: 203-897-0107
  • Fax: 203-879-0206
Mailing address:
  • Phone: 203-578-0409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number007482
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: