Provider Demographics
NPI:1588654537
Name:FOX, TARA (MOT OTRL)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:FOX
Suffix:
Gender:F
Credentials:MOT OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 SHADOW WOOD BND
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-5713
Mailing Address - Country:US
Mailing Address - Phone:678-333-5832
Mailing Address - Fax:
Practice Address - Street 1:156 SHADOW WOOD BND
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-5713
Practice Address - Country:US
Practice Address - Phone:678-333-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 11705225XP0200X
GAOT004571225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890417100Medicaid