Healthcare Provider Details

I. General information

NPI: 1093647885
Provider Name (Legal Business Name): TARA LAKES OT/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA BRISTOL OT/L

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10049 E DYNAMITE BLVD STE 130
SCOTTSDALE AZ
85262-3695
US

IV. Provider business mailing address

18126 W PUGET AVE
WADDELL AZ
85355-7505
US

V. Phone/Fax

Practice location:
  • Phone: 480-419-0848
  • Fax:
Mailing address:
  • Phone: 317-985-1294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOTH-006632
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: