Provider Demographics
NPI:1235787888
Name:GORMAN, TARA ROSE (OTR/L)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ROSE
Last Name:GORMAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-6167
Mailing Address - Country:US
Mailing Address - Phone:484-241-6279
Mailing Address - Fax:
Practice Address - Street 1:779 RIDGEBURY RD
Practice Address - Street 2:
Practice Address - City:SLATE HILL
Practice Address - State:NY
Practice Address - Zip Code:10973-3900
Practice Address - Country:US
Practice Address - Phone:845-381-9658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023037225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist