Provider Demographics
NPI:1821655358
Name:BRYAN, TARA RAHDIKA (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:RAHDIKA
Last Name:BRYAN
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ROUTE 88
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-2320
Mailing Address - Country:US
Mailing Address - Phone:732-367-4700
Mailing Address - Fax:
Practice Address - Street 1:1500 ROUTE 88
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-2320
Practice Address - Country:US
Practice Address - Phone:732-367-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06451500104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid