Provider Demographics
NPI:1871714139
Name:MCDONALD, TINA MARIE (PTA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:MCDONALD
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 1:807 TARAWOOD LN
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-6639
Mailing Address - Country:US
Mailing Address - Phone:813-654-9555
Mailing Address - Fax:
Practice Address - Street 1:807 TARAWOOD LN
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-6639
Practice Address - Country:US
Practice Address - Phone:813-654-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 001295225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant