Provider Demographics
NPI:1053573873
Name:MCCRADY, TARA ROSE (BS)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ROSE
Last Name:MCCRADY
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 PHOENIX AVE
Mailing Address - Street 2:BLDG. #2
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852
Mailing Address - Country:US
Mailing Address - Phone:978-453-8331
Mailing Address - Fax:
Practice Address - Street 1:126 PHOENIX AVE
Practice Address - Street 2:BLDG. #2
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852
Practice Address - Country:US
Practice Address - Phone:978-453-8331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-02
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH85689222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist