Provider Demographics
NPI:1245966811
Name:GALLAGHER, TARA LAYNE (COTA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LAYNE
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 CANDICE WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-4621
Mailing Address - Country:US
Mailing Address - Phone:314-420-4441
Mailing Address - Fax:
Practice Address - Street 1:1 MERAMEC BLUFFS DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-3309
Practice Address - Country:US
Practice Address - Phone:636-861-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022028288224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty