Provider Demographics
NPI:1689888695
Name:LUTALI, TANYA MARIE (CERTIFIED OCCUPATION)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:MARIE
Last Name:LUTALI
Suffix:
Gender:F
Credentials:CERTIFIED OCCUPATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:1315 NW 185TH AVENUE
Mailing Address - Street 2:#216
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006
Mailing Address - Country:US
Mailing Address - Phone:808-381-2807
Mailing Address - Fax:
Practice Address - Street 1:4560 SE INTERNATIONAL WAY
Practice Address - Street 2:CONSONUS REHAB SERVICES
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:971-206-5140
Practice Address - Fax:971-206-5209
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1030742224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant