Provider Demographics
NPI:1497062079
Name:WILD-PEACH, TANYA LEILA (MS OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:LEILA
Last Name:WILD-PEACH
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 GEARY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-2910
Mailing Address - Country:US
Mailing Address - Phone:908-756-3689
Mailing Address - Fax:
Practice Address - Street 1:1015 AMBOY AVE
Practice Address - Street 2:GRS HERITAGE AT CLARA BARTON
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2825
Practice Address - Country:US
Practice Address - Phone:732-346-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00486800225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist