Healthcare Provider Details

I. General information

NPI: 1366944266
Provider Name (Legal Business Name): SHELBY R TARANGO OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 EL CAMINO CAMPO
CORRALES NM
87048-7518
US

IV. Provider business mailing address

3915 TUNDRA SWAN CT NW
ALBUQUERQUE NM
87120-4113
US

V. Phone/Fax

Practice location:
  • Phone: 719-289-5766
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3872
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: