Provider Demographics
NPI:1679972202
Name:DANIELS, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:DANIELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595-20 ROUTE 25A
Mailing Address - Street 2:SUITE 20
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764
Mailing Address - Country:US
Mailing Address - Phone:631-744-5500
Mailing Address - Fax:
Practice Address - Street 1:595-20 ROUTE 25A
Practice Address - Street 2:SUITE 20
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764
Practice Address - Country:US
Practice Address - Phone:631-744-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP93879104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker