Provider Demographics
NPI:1558301846
Name:DARE, TEGAN KATHLEEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:TEGAN
Middle Name:KATHLEEN
Last Name:DARE
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 1:3466 FAY AVE
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-7436
Mailing Address - Country:US
Mailing Address - Phone:310-204-0581
Mailing Address - Fax:310-204-0581
Practice Address - Street 1:415 N CRESCENT DR
Practice Address - Street 2:SUITE 130
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4860
Practice Address - Country:US
Practice Address - Phone:310-497-0383
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 865225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1013058OtherNBCOT
CAOT 865OtherCBOT