Provider Demographics
NPI:1568618205
Name:KIRBY, TARA AMBER (COTA)
Entity Type:Individual
Prefix:MISS
First Name:TARA
Middle Name:AMBER
Last Name:KIRBY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 N CHICKASAW ST
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-2408
Mailing Address - Country:US
Mailing Address - Phone:405-207-7237
Mailing Address - Fax:
Practice Address - Street 1:3030 NW EXPRESSWAY STE 809
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-5466
Practice Address - Country:US
Practice Address - Phone:405-917-7160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK341224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant