Basic Information
| Provider Information | |||||||||
| NPI: | 1265902100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAPHOUSE | ||||||||
| FirstName: | BREANNA | ||||||||
| MiddleName: | EVE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | AT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAPHOUSE | ||||||||
| OtherFirstName: | BREANNA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | AT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 401 W KENNEDY BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336061450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1111111111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 W KENNEDY BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336061450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1111111111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2018 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.