Provider Demographics
NPI:1184081499
Name:IVANOVITCH, TARA (LCSW, LAC)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:IVANOVITCH
Suffix:
Gender:F
Credentials:LCSW, LAC
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 17962
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-7962
Mailing Address - Country:US
Mailing Address - Phone:406-880-3123
Mailing Address - Fax:844-500-6858
Practice Address - Street 1:2112 DIXON AVE STE 4
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8226
Practice Address - Country:US
Practice Address - Phone:406-880-3123
Practice Address - Fax:844-500-6858
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-19
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT42101YA0400X
MT254031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)