Healthcare Provider Details

I. General information

NPI: 1184188450
Provider Name (Legal Business Name): TARA BURBRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 LINK DR
ROCKLEIGH NJ
07647-2504
US

IV. Provider business mailing address

5 MILFORD CT
NANUET NY
10954-3842
US

V. Phone/Fax

Practice location:
  • Phone: 201-784-1414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number46TA09072900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: