Provider Demographics
NPI:1639693278
Name:FEDDERN, TARA BANKS (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:BANKS
Last Name:FEDDERN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:BANKS
Other - Last Name:MALONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6477 MOSSY BOULDER DR
Mailing Address - Street 2:WONDER THERAPEUTIC SERVICES, LLC
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542
Mailing Address - Country:US
Mailing Address - Phone:404-406-8272
Mailing Address - Fax:
Practice Address - Street 1:4319 SOUTH LEE STREET SUITE 300
Practice Address - Street 2:CHANDLER SPEECH AND LANGUAGE SERVICES, LLC
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518
Practice Address - Country:US
Practice Address - Phone:678-288-9770
Practice Address - Fax:678-288-9774
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006793225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003194815AMedicaid