Provider Demographics
NPI:1659763233
Name:GANN, TARA BETH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:BETH
Last Name:GANN
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 1:920 FREDERICA ST STE 211
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-3077
Mailing Address - Country:US
Mailing Address - Phone:270-316-8798
Mailing Address - Fax:270-683-1123
Practice Address - Street 1:920 FREDERICA ST STE 211
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-3077
Practice Address - Country:US
Practice Address - Phone:270-316-8798
Practice Address - Fax:270-683-1123
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical