Provider Demographics
NPI:1578881926
Name:MARSHA TARDIVO, LCSW, PA
Entity Type:Organization
Organization Name:MARSHA TARDIVO, LCSW, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:TARDIVO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:561-452-0304
Mailing Address - Street 1:4669 ISLAND REEF DR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33449-8398
Mailing Address - Country:US
Mailing Address - Phone:561-452-0304
Mailing Address - Fax:561-204-4177
Practice Address - Street 1:1035 S STATE ROAD 7
Practice Address - Street 2:SUITE 315-08
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6134
Practice Address - Country:US
Practice Address - Phone:561-452-0304
Practice Address - Fax:561-204-4177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW77091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty