Provider Demographics
NPI:1760524458
Name:FORTNER, TARA ANNE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:ANNE
Last Name:FORTNER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7805 GRANT LN
Mailing Address - Street 2:APT 203
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2434
Mailing Address - Country:US
Mailing Address - Phone:913-439-8332
Mailing Address - Fax:
Practice Address - Street 1:757 ARMSTRONG AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66101-2701
Practice Address - Country:US
Practice Address - Phone:913-233-3342
Practice Address - Fax:913-233-3395
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6539104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS17-4602Medicare ID - Type Unspecified
KS3620000Medicare ID - Type Unspecified