Provider Demographics
NPI:1023250594
Name:MANNERY, TARAH AURELIA (OTR/L, MS)
Entity type:Individual
Prefix:MRS
First Name:TARAH
Middle Name:AURELIA
Last Name:MANNERY
Suffix:
Gender:F
Credentials:OTR/L, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6208 FERNCREEK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2003
Mailing Address - Country:US
Mailing Address - Phone:601-259-8517
Mailing Address - Fax:
Practice Address - Street 1:731 AVIGNON DR STE 4
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157
Practice Address - Country:US
Practice Address - Phone:601-300-2624
Practice Address - Fax:601-510-3512
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015655225X00000X
NJ225X00000X
MSOT1714225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist