Provider Demographics
NPI:1023238201
Name:ROMANO, TARA S (LMSW ACSW LMFT BCD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:S
Last Name:ROMANO
Suffix:
Gender:F
Credentials:LMSW ACSW LMFT BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 120125
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49528-0103
Mailing Address - Country:US
Mailing Address - Phone:616-396-6285
Mailing Address - Fax:616-355-7704
Practice Address - Street 1:607 HERITAGE CT
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-5481
Practice Address - Country:US
Practice Address - Phone:616-396-6285
Practice Address - Fax:616-355-7704
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITR0342851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P69546OtherBCN
08913650OtherBCBS