Provider Demographics
NPI:1609656743
Name:USSERY, TANYA C (OTA)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:C
Last Name:USSERY
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 QUEENS LN
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2840
Mailing Address - Country:US
Mailing Address - Phone:763-898-6228
Mailing Address - Fax:
Practice Address - Street 1:3401 E MEDICINE LAKE BLVD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2307
Practice Address - Country:US
Practice Address - Phone:763-559-3123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201450224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant