Healthcare Provider Details

I. General information

NPI: 1043742182
Provider Name (Legal Business Name): TARA HANLEY OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 S LIBERTY ST
WINSTON SALEM NC
27101-5213
US

IV. Provider business mailing address

PO BOX 749
BELMONT NC
28012-0749
US

V. Phone/Fax

Practice location:
  • Phone: 336-934-4058
  • Fax: 743-255-3010
Mailing address:
  • Phone: 704-869-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number17674
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number021316-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: