Provider Demographics
NPI:1235285610
Name:CREWS, TARA MICHELE (MS OTRL)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MICHELE
Last Name:CREWS
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 CHENA RD APT 9
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-1322
Mailing Address - Country:US
Mailing Address - Phone:907-356-1319
Mailing Address - Fax:
Practice Address - Street 1:1049 CHENA RD APT 9
Practice Address - Street 2:
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-1322
Practice Address - Country:US
Practice Address - Phone:907-356-1319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1711225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOT 1711Medicaid