Tara Broccolo

Primary specialty

SpecialistTaxonomy code 174400000X

License

649366951 Issued in NY

Practice address

2111 Hudson Ave
Irondequoit, NY 14617-4346

Phone

(585) 520-1783

NPI assigned

Nov 24, 2014

Last updated

Nov 24, 2014By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Stepping Stones Learning Center

  • Early Intervention Provider Agency
  • Rochester, NY
  • NPI 1487893269
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1416787200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1416787200000",
    "number": "1821495581",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1628 GLENDOWAN TER",
            "city": "WEBSTER",
            "state": "NY",
            "postal_code": "145808571",
            "telephone_number": "585-520-1783"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2111 HUDSON AVE",
            "city": "IRONDEQUOIT",
            "state": "NY",
            "postal_code": "146174346",
            "telephone_number": "585-520-1783"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BROCCOLO",
        "first_name": "TARA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2014-11-24",
        "last_updated": "2014-11-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "NY",
            "license": "649366951",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Terrence Annable
• Cross Bauer, LMSW
• Marissa Baughman
• Dominique S Blue
• David V Bruni
• Joseph Andrew Collins, RN
• Kimberly Ann Couse
• Latoya Michelle Crockton
• Christine L Donato, PHARMD

• Specialist in Irondequoit, NY
• Providers in Irondequoit, NY by specialty
• Specialist in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 24, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.