Provider Demographics
NPI:1083134605
Name:PETRUNGARO, TARA JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JEAN
Last Name:PETRUNGARO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 LORENZO CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-2279
Mailing Address - Country:US
Mailing Address - Phone:631-708-9309
Mailing Address - Fax:
Practice Address - Street 1:181 LORENZO CIR
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2279
Practice Address - Country:US
Practice Address - Phone:631-708-9309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-24
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075742-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical