Provider Demographics
NPI:1407010077
Name:DAVIS, TARA D (LSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321B MAPLEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-2999
Mailing Address - Country:US
Mailing Address - Phone:848-200-6128
Mailing Address - Fax:
Practice Address - Street 1:219 TAYLORS MILLS RD
Practice Address - Street 2:
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3255
Practice Address - Country:US
Practice Address - Phone:908-415-2042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420795Medicaid