Basic Information
| Provider Information | |||||||||
| NPI: | 1902144165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | SUZANNE | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 821 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629950821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187716838 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420010749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704449661 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2013 | ||||||||
| LastUpdateDate: | 01/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | A5079 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.