Provider Demographics
NPI:1013671080
Name:SULLIVAN-BUTRICA, TARA LEIGH (LCSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LEIGH
Last Name:SULLIVAN-BUTRICA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 CEDARCROFT AVE
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:NJ
Mailing Address - Zip Code:08106-2117
Mailing Address - Country:US
Mailing Address - Phone:215-594-9402
Mailing Address - Fax:
Practice Address - Street 1:4700 N CONGRESS AVE SUITE 301
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2117
Practice Address - Country:US
Practice Address - Phone:856-454-3104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0219441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical