Provider Demographics
NPI:1861006728
Name:FEDEWA, TARA ANN (OTR/L)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ANN
Last Name:FEDEWA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 SERVICE RD STE A202
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-355-7648
Mailing Address - Fax:517-432-1319
Practice Address - Street 1:4660 S HAGADORN RD STE 400
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5353
Practice Address - Country:US
Practice Address - Phone:517-355-7648
Practice Address - Fax:517-432-1319
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2024-11-12
Deactivation Date:2021-07-19
Deactivation Code:
Reactivation Date:2024-11-08
Provider Licenses
StateLicense IDTaxonomies
MI5201013965225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist