Provider Demographics
NPI:1841200011
Name:BRUNSWICK, TARA MARIE (MS, L C S W)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MARIE
Last Name:BRUNSWICK
Suffix:
Gender:F
Credentials:MS, L C S W
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 ROUTE 111
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3712
Mailing Address - Country:US
Mailing Address - Phone:631-920-8326
Mailing Address - Fax:631-920-8468
Practice Address - Street 1:11 ROUTE 111
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3712
Practice Address - Country:US
Practice Address - Phone:631-920-8326
Practice Address - Fax:631-920-8468
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074196-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical