Provider Demographics
NPI:1871648485
Name:TAYE, INTESAR A (OTRL)
Entity Type:Individual
Prefix:
First Name:INTESAR
Middle Name:A
Last Name:TAYE
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 1:30925 WINDY HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3833
Mailing Address - Country:US
Mailing Address - Phone:440-779-0991
Mailing Address - Fax:
Practice Address - Street 1:10011 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-4701
Practice Address - Country:US
Practice Address - Phone:216-791-8363
Practice Address - Fax:216-791-2539
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0349128374U00000X
OHOT-2774225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH340753561031OtherCARESOURCE ID