Provider Demographics
NPI:1295860344
Name:TIVNAN, TARA MICHELLE (LMHC)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:MICHELLE
Last Name:TIVNAN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 ELM ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1967
Mailing Address - Country:US
Mailing Address - Phone:508-756-3750
Mailing Address - Fax:508-756-2729
Practice Address - Street 1:111 ELM ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1967
Practice Address - Country:US
Practice Address - Phone:508-756-3750
Practice Address - Fax:508-756-2729
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4803101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health