Healthcare Provider Details

I. General information

NPI: 1861006728
Provider Name (Legal Business Name): TARA ANN FEDEWA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date: 07/19/2021
Reactivation Date: 11/08/2024

III. Provider practice location address

4660 S HAGADORN RD STE 400
EAST LANSING MI
48823-5353
US

IV. Provider business mailing address

804 SERVICE RD STE A202
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-355-7648
  • Fax: 517-432-1319
Mailing address:
  • Phone: 517-355-7648
  • Fax: 517-432-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201013965
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: