Provider Demographics
NPI:1639223282
Name:RILEY, TARA LYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYN
Last Name:RILEY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYN
Other - Last Name:LAVY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:75-5851 KUAKINI HWY
Mailing Address - Street 2:#34
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:63740
Mailing Address - Country:US
Mailing Address - Phone:429-842-7161
Mailing Address - Fax:479-521-5439
Practice Address - Street 1:75-127 LUNAPULE ROAD
Practice Address - Street 2:#11
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740
Practice Address - Country:US
Practice Address - Phone:808-326-7778
Practice Address - Fax:808-326-4063
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1131225XP0200X
HIOT-947225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
5T431OtherAR BLUE CROSS BLUE SHEILD
AR130525721Medicaid