Provider Demographics
NPI:1134608441
Name:MASTROIANNI, TARA MARIE (LPC)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MARIE
Last Name:MASTROIANNI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MARIE
Other - Last Name:SEGREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 HOLIDAY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2846
Mailing Address - Country:US
Mailing Address - Phone:609-280-0771
Mailing Address - Fax:
Practice Address - Street 1:101 HOLIDAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2846
Practice Address - Country:US
Practice Address - Phone:609-280-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00629900101YP2500X
NJ37LC00285600101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty