Provider Demographics
NPI:1093286189
Name:BIRKENSTOCK, TARALEE WRIGHT (LCSW)
Entity Type:Individual
Prefix:
First Name:TARALEE
Middle Name:WRIGHT
Last Name:BIRKENSTOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TARALEE
Other - Middle Name:JANEN
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:1650 S TOPAZ WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4474
Mailing Address - Country:US
Mailing Address - Phone:208-605-7070
Mailing Address - Fax:
Practice Address - Street 1:3351 EASTBROOK DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5744
Practice Address - Country:US
Practice Address - Phone:970-500-0164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO09929934104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker