Healthcare Provider Details

I. General information

NPI: 1508178161
Provider Name (Legal Business Name): TARA MICHAELS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2010
Last Update Date: 07/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3936 AMBOY RD
STATEN ISLAND NY
10308-2406
US

IV. Provider business mailing address

1658 E 37TH ST
BROOKLYN NY
11234-4221
US

V. Phone/Fax

Practice location:
  • Phone: 718-317-6390
  • Fax:
Mailing address:
  • Phone: 718-836-0477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number012478
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number012478
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number012478
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: