Provider Demographics
NPI:1275827081
Name:OTTER, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:OTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 S CHESTNUT DR
Mailing Address - Street 2:
Mailing Address - City:DRUMS
Mailing Address - State:PA
Mailing Address - Zip Code:18222-2052
Mailing Address - Country:US
Mailing Address - Phone:570-233-4384
Mailing Address - Fax:
Practice Address - Street 1:156 S CHESTNUT DR
Practice Address - Street 2:
Practice Address - City:DRUMS
Practice Address - State:PA
Practice Address - Zip Code:18222-2052
Practice Address - Country:US
Practice Address - Phone:570-233-4384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI000069225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant