Provider Demographics
NPI:1760021513
Name:STABOSZ, TAMARA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:ANN
Last Name:STABOSZ
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 1:76 ASHWORTH DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:NC
Mailing Address - Zip Code:28730-9229
Mailing Address - Country:US
Mailing Address - Phone:815-412-4003
Mailing Address - Fax:
Practice Address - Street 1:76 ASHWORTH DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:NC
Practice Address - Zip Code:28730-9229
Practice Address - Country:US
Practice Address - Phone:815-412-4003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0114301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical