MEDICARE: MRS. TARA SUZANNE GARRETT MS PT CLT LA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	014055-1	NY
2	225100000X	Physical Therapist	014055	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000627413001	OTHER	NY	BLUE CROSS BLUE SHIELD
2	9312131	OTHER	NY	INDEPENDENT HEALTH

General Provider Information

NPI Number	:	1629141064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TARA SUZANNE GARRETT MS PT CLT LA

Provider Business Mailing Address
First Line	:	705 MAPLE RD STE 100
Second Line	:
City	:	WILLIAMSVILLE
State	:	NY
Zip	:	14221-3291
Country	:	US
Telephone Number	:	716-805-7360
Fax Number	:	716-580-7396

Provider Business Practice Location Address
First Line	:	705 MAPLE RD STE 100
Second Line	:
City	:	WILLIAMSVILLE
State	:	NY
Zip	:	14221-3291
Country	:	US
Telephone Number	:	716-580-7360
Fax Number	:	716-580-7396

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	12/02/2019

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