Healthcare Provider Details

I. General information

NPI: 1689630980
Provider Name (Legal Business Name): TARA LYNN GAUSE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA L CASAL

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11286 BOYETTE RD
RIVERVIEW FL
33569-8021
US

IV. Provider business mailing address

5901 E FOWLER AVE STE 100
TEMPLE TERRACE FL
33617-2305
US

V. Phone/Fax

Practice location:
  • Phone: 813-978-9700
  • Fax: 813-558-6185
Mailing address:
  • Phone: 813-987-9700
  • Fax: 813-558-6187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT20406
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: