Provider Demographics
NPI:1629387253
Name:FISCHETTI, TARA (OT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:FISCHETTI
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 OLD HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2526
Mailing Address - Country:US
Mailing Address - Phone:631-424-3832
Mailing Address - Fax:
Practice Address - Street 1:23 OLD HICKORY LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2526
Practice Address - Country:US
Practice Address - Phone:631-424-3832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009976-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist