Provider Demographics
NPI:1760459853
Name:YOUNG, TARA NANETTE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:NANETTE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 E 57TH PLACE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135
Mailing Address - Country:US
Mailing Address - Phone:918-742-2309
Mailing Address - Fax:
Practice Address - Street 1:8421 E 61ST ST SUITE P
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133
Practice Address - Country:US
Practice Address - Phone:918-459-9305
Practice Address - Fax:918-250-6032
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOT384225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist