Provider Demographics
NPI:1619010857
Name:TARDY, PAUL J (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:J
Last Name:TARDY
Suffix:
Gender:M
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 1:105 SERENDIPITY WAY # D
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-6999
Mailing Address - Country:US
Mailing Address - Phone:803-556-3911
Mailing Address - Fax:866-887-4617
Practice Address - Street 1:105 SERENDIPITY WAY # D
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-6999
Practice Address - Country:US
Practice Address - Phone:803-556-3911
Practice Address - Fax:866-887-4617
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3735225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME099039OtherANTHEM
MEP00393431OtherRAILROAD MEDICARE
ME7052332OtherAETNA
ME11513654OtherCAQH
ME266140000Medicaid
ME11513654OtherCAQH