Provider Demographics
NPI:1851626261
Name:NICOTRA CLEMENTE, TARA KATHLEEN (MSW)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:KATHLEEN
Last Name:NICOTRA CLEMENTE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21380 LORAIN RD STE 102
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-2144
Mailing Address - Country:US
Mailing Address - Phone:216-395-7523
Mailing Address - Fax:
Practice Address - Street 1:21380 LORAIN RD STE 102
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2144
Practice Address - Country:US
Practice Address - Phone:216-395-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-03
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI18009161041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical