Basic Information
| Provider Information | |||||||||
| NPI: | 1801530415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEROSA | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2712 RAY PL | ||||||||
| Address2: | |||||||||
| City: | NORTH BELLMORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117102035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163618963 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1250 WATERS PL | ||||||||
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| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104612720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184099444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2022 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 026698 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.