Provider Demographics
NPI:1629519327
Name:INGRAM, TARAH (OTR)
Entity Type:Individual
Prefix:
First Name:TARAH
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:TARAH
Other - Middle Name:
Other - Last Name:MIKOLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:326 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-1570
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:326 S 9TH ST
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-1570
Practice Address - Country:US
Practice Address - Phone:509-836-4835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60183595225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist