Provider Demographics
NPI:1639296528
Name:LIBRIZZI, TARA (LCSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LIBRIZZI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 139
Mailing Address - Street 2:
Mailing Address - City:MACHIAS
Mailing Address - State:ME
Mailing Address - Zip Code:04654-0139
Mailing Address - Country:US
Mailing Address - Phone:207-255-0996
Mailing Address - Fax:
Practice Address - Street 1:1 STACKPOLE ROAD
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654
Practice Address - Country:US
Practice Address - Phone:207-255-0996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC61371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME282860099Medicaid
ME282860099Medicaid