Provider Demographics
NPI:1649848433
Name:WOOTEN, TAIESHA (LCSW)
Entity type:Individual
Prefix:
First Name:TAIESHA
Middle Name:
Last Name:WOOTEN
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 1:107 COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:HAVERSTRAW
Mailing Address - State:NY
Mailing Address - Zip Code:10927-1034
Mailing Address - Country:US
Mailing Address - Phone:845-598-8731
Mailing Address - Fax:
Practice Address - Street 1:107 COOLIDGE ST
Practice Address - Street 2:
Practice Address - City:HAVERSTRAW
Practice Address - State:NY
Practice Address - Zip Code:10927-1034
Practice Address - Country:US
Practice Address - Phone:845-598-8731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0914411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical