Provider Demographics
NPI:1740775881
Name:CERVANO, TARA (MS, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:CERVANO
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 LACKAWANNA AVE APT 138
Mailing Address - Street 2:
Mailing Address - City:WALLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07057-2092
Mailing Address - Country:US
Mailing Address - Phone:845-728-8407
Mailing Address - Fax:
Practice Address - Street 1:899 PINES LAKE DR W
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-6107
Practice Address - Country:US
Practice Address - Phone:201-744-5740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00890300225XP0019X
NJ46TA09088400224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant