Provider Demographics
NPI:1699371419
Name:GRAVITT, TARA (LCSW, CAADC, CCM)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GRAVITT
Suffix:
Gender:F
Credentials:LCSW, CAADC, CCM
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 9142
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-9142
Mailing Address - Country:US
Mailing Address - Phone:267-308-4303
Mailing Address - Fax:
Practice Address - Street 1:1601 WALNUT ST STE 1017
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-2906
Practice Address - Country:US
Practice Address - Phone:267-308-4303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA8157101YA0400X
PA4237640171M00000X
PACW0208141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty