Provider Demographics
NPI:1871563783
Name:MCCANN, TARA G (MSOT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:G
Last Name:MCCANN
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6430 SE JENNINGS AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-6317
Mailing Address - Country:US
Mailing Address - Phone:360-907-5874
Mailing Address - Fax:
Practice Address - Street 1:7927 SE ORIENT DR
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080
Practice Address - Country:US
Practice Address - Phone:503-663-0332
Practice Address - Fax:503-663-1114
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1032940225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227783Medicaid