Provider Demographics
NPI:1023825080
Name:RIVERA, TARA ANGELA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ANGELA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 RIVER PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4803
Mailing Address - Country:US
Mailing Address - Phone:407-694-7042
Mailing Address - Fax:
Practice Address - Street 1:1915 RIVER PARK BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4803
Practice Address - Country:US
Practice Address - Phone:407-694-7042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22193225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant