Provider Demographics
NPI:1447750484
Name:TAVARES, MARY BETH (LICSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:TAVARES
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:B6 BRISTOL WOODS DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:RI
Mailing Address - Zip Code:02809-2746
Mailing Address - Country:US
Mailing Address - Phone:401-573-8168
Mailing Address - Fax:
Practice Address - Street 1:B6 BRISTOL WOODS DR
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:RI
Practice Address - Zip Code:02809-2746
Practice Address - Country:US
Practice Address - Phone:401-573-8168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1193571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical