Basic Information
| Provider Information | |||||||||
| NPI: | 1194074708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEARY | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | GAIL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOZMENSKI | ||||||||
| OtherFirstName: | TAMMY | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11296 WINDSOR CT | ||||||||
| Address2: | |||||||||
| City: | IJAMSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217548812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2402858963 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 844 WASHINGTON RD STE 209 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211576876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108765600 | ||||||||
| FaxNumber: | 4108761623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 04829 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.