Provider Demographics
NPI:1417567769
Name:BLAIR, TARA BREANN (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:BREANN
Last Name:BLAIR
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:BREANN
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3718 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3566
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3718 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3566
Practice Address - Country:US
Practice Address - Phone:903-793-6135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX224Z00000X
224Z00000X
TX124396225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant