Provider Demographics
NPI:1114007580
Name:DAVIS, TARAH (OT001029)
Entity Type:Individual
Prefix:
First Name:TARAH
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OT001029
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4460 CELEBRATION DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-6370
Mailing Address - Country:US
Mailing Address - Phone:404-699-2886
Mailing Address - Fax:
Practice Address - Street 1:1200 LAKE HEARN DR NE
Practice Address - Street 2:SUITE 250
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-1415
Practice Address - Country:US
Practice Address - Phone:404-943-1070
Practice Address - Fax:404-943-0890
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001029225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT001029Medicaid