Provider Demographics
NPI:1245435007
Name:PULLEN, TARA K (LCSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:K
Last Name:PULLEN
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 1:49 PLANTATION LN
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:ME
Mailing Address - Zip Code:04090-6466
Mailing Address - Country:US
Mailing Address - Phone:207-318-4831
Mailing Address - Fax:
Practice Address - Street 1:4 WASHINGTON ST
Practice Address - Street 2:SUITE 300
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-3031
Practice Address - Country:US
Practice Address - Phone:207-318-4831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC99571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431537699Medicaid
ME431537699Medicaid