Provider Demographics
NPI:1508178161
Name:MICHAELS, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:MICHAELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1658 E 37TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4221
Mailing Address - Country:US
Mailing Address - Phone:718-836-0477
Mailing Address - Fax:
Practice Address - Street 1:3936 AMBOY RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-2406
Practice Address - Country:US
Practice Address - Phone:718-317-6390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-11
Last Update Date:2010-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012478225X00000X, 225XP0019X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics