Provider Demographics
NPI:1326225004
Name:MILLER, TARA J (MSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:J
Last Name:MILLER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10811 CARDINAL CIR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-7970
Mailing Address - Country:US
Mailing Address - Phone:574-933-1201
Mailing Address - Fax:574-968-7404
Practice Address - Street 1:403 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617
Practice Address - Country:US
Practice Address - Phone:574-283-1107
Practice Address - Fax:574-283-1131
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005729A1041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical