Provider Demographics
NPI:1649457045
Name:TATYANA KOMAR OTR/L LLC
Entity type:Organization
Organization Name:TATYANA KOMAR OTR/L LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MA, OTR/L
Authorized Official - Phone:856-616-2385
Mailing Address - Street 1:1500 KINGS HWY N STE B104
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-2304
Mailing Address - Country:US
Mailing Address - Phone:856-616-2385
Mailing Address - Fax:856-616-2385
Practice Address - Street 1:1500 N KINGS HWY
Practice Address - Street 2:SUITE #104
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2304
Practice Address - Country:US
Practice Address - Phone:856-616-2385
Practice Address - Fax:856-616-2385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00097700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6192460001Medicare NSC