Provider Demographics
NPI:1427110741
Name:DIKEMAN, TARA LYNN (MED,OTR)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:LYNN
Last Name:DIKEMAN
Suffix:
Gender:F
Credentials:MED,OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2665 A DUTTON MEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-7730
Mailing Address - Country:US
Mailing Address - Phone:707-565-8185
Mailing Address - Fax:707-565-8190
Practice Address - Street 1:2665 A DUTTON MEADOW AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7730
Practice Address - Country:US
Practice Address - Phone:707-565-8185
Practice Address - Fax:707-565-8190
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5765225XP0200X
CA5905225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301830Medicaid