Provider Demographics
NPI:1023721867
Name:DONDERO, LARA (PTA)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:DONDERO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6548 WINDOVER WAY
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-7565
Mailing Address - Country:US
Mailing Address - Phone:321-684-0187
Mailing Address - Fax:
Practice Address - Street 1:951 N WASHINGTON AVE BLDG 4
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2194
Practice Address - Country:US
Practice Address - Phone:321-684-0187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA29667225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant