Provider Demographics
NPI:1174916597
Name:OTTERBEIN, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:OTTERBEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:MACULA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:333 EARLE OVINGTON BLVD
Mailing Address - Street 2:SUITE
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11553-3610
Mailing Address - Country:US
Mailing Address - Phone:516-321-2424
Mailing Address - Fax:516-321-2424
Practice Address - Street 1:776 N RTE 17
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3108
Practice Address - Country:US
Practice Address - Phone:201-225-9222
Practice Address - Fax:201-225-9223
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01599300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ255015Medicare PIN