Provider Demographics
NPI:1386019990
Name:DIVELY, TARA LYNN (MA, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYNN
Last Name:DIVELY
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17102-2147
Mailing Address - Country:US
Mailing Address - Phone:717-221-8004
Mailing Address - Fax:717-221-8006
Practice Address - Street 1:29 N MARKET ST
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-1924
Practice Address - Country:US
Practice Address - Phone:717-221-8004
Practice Address - Fax:717-221-8006
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF0005851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical