Provider Demographics
NPI:1487297776
Name:FARRY, TARA LYNN (OTR/L)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:FARRY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:PALOMINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24392 CARACAS ST
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-1319
Mailing Address - Country:US
Mailing Address - Phone:949-443-0701
Mailing Address - Fax:
Practice Address - Street 1:25 FELDSPAR WAY
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-3518
Practice Address - Country:US
Practice Address - Phone:949-584-1603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-20
Last Update Date:2019-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT16595225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912416744Medicaid