Provider Demographics
NPI:1699192013
Name:BEATTY, TARA (LCSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BEATTY
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 1:40 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-5702
Mailing Address - Country:US
Mailing Address - Phone:860-887-6536
Mailing Address - Fax:
Practice Address - Street 1:40 BROADWAY
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-5702
Practice Address - Country:US
Practice Address - Phone:860-887-6536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0071161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical