Provider Demographics
NPI:1245383637
Name:TUGUN, TARISA MARIE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:TARISA
Middle Name:MARIE
Last Name:TUGUN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 BROOKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6085
Mailing Address - Country:US
Mailing Address - Phone:586-703-6316
Mailing Address - Fax:
Practice Address - Street 1:1428 BROOKFIELD DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-6085
Practice Address - Country:US
Practice Address - Phone:586-703-6316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9153225X00000X
MI5201004575225X00000X
NM3621225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201004575OtherSTATE OF MICHIGAN OCCUPATIONAL THERAPIST REGISTRATION