Provider Demographics
NPI:1922293125
Name:BLACK, TARA (LICSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01035-9521
Mailing Address - Country:US
Mailing Address - Phone:413-240-4093
Mailing Address - Fax:
Practice Address - Street 1:185 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01035-9521
Practice Address - Country:US
Practice Address - Phone:201-248-9878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MA1168791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker