Provider Demographics
NPI:1992853279
Name:FOURNIER, TARA-ELLEN (LICSW)
Entity Type:Individual
Prefix:
First Name:TARA-ELLEN
Middle Name:
Last Name:FOURNIER
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 1:67 LAUREL HILL LN
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01520-1619
Mailing Address - Country:US
Mailing Address - Phone:508-829-4190
Mailing Address - Fax:
Practice Address - Street 1:198 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2200
Practice Address - Country:US
Practice Address - Phone:508-438-0110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1122561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAFO-P23996Medicare ID - Type Unspecified