Provider Demographics
NPI:1770063372
Name:LITZEL, TARA JANAE (OT/L, COTA/L)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:JANAE
Last Name:LITZEL
Suffix:
Gender:F
Credentials:OT/L, COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 S KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-2107
Mailing Address - Country:US
Mailing Address - Phone:620-212-1825
Mailing Address - Fax:
Practice Address - Street 1:629 S PLUMMER AVE
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720-1928
Practice Address - Country:US
Practice Address - Phone:620-432-5379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01341224Z00000X
KST-05144225X00000X
KS17-03599225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS17-03599OtherKANSAS STATE BOARD OF HEALING ARTS
426052OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY
KS18-01341OtherKANSAS STATE BOARD OF HEALING ARTS