Healthcare Provider Details

I. General information

NPI: 1619149143
Provider Name (Legal Business Name): AMBER GRACE TAGG O.T.R/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10067 SOUTH AVE. 10E #46
YUMA AZ
85365
US

IV. Provider business mailing address

33 OLD BOSTON RD
TOPSFIELD MA
01983-2509
US

V. Phone/Fax

Practice location:
  • Phone: 605-430-9361
  • Fax:
Mailing address:
  • Phone: 207-615-3808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number10967
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4003
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: