1639693278 NPI number — MRS. TARA BANKS FEDDERN OTR/L

Table of content: MRS. TARA BANKS FEDDERN OTR/L (NPI 1639693278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639693278 NPI number — MRS. TARA BANKS FEDDERN OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FEDDERN
Provider First Name:
TARA
Provider Middle Name:
BANKS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MALONE
Provider Other First Name:
TARA
Provider Other Middle Name:
BANKS
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639693278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6477 MOSSY BOULDER DR
Provider Second Line Business Mailing Address:
WONDER THERAPEUTIC SERVICES, LLC
Provider Business Mailing Address City Name:
FLOWERY BRANCH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-406-8272
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4319 SOUTH LEE STREET SUITE 300
Provider Second Line Business Practice Location Address:
CHANDLER SPEECH AND LANGUAGE SERVICES, LLC
Provider Business Practice Location Address City Name:
BUFORD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-288-9770
Provider Business Practice Location Address Fax Number:
678-288-9774
Provider Enumeration Date:
07/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  OT006793 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003194815A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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