Provider Demographics
NPI:1740613769
Name:PINNACOLI, TARA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:PINNACOLI
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 1:630 NE ZEBRINA SENDA
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-6665
Mailing Address - Country:US
Mailing Address - Phone:772-215-6156
Mailing Address - Fax:772-210-1272
Practice Address - Street 1:8142 SE FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:HOBE SOUND
Practice Address - State:FL
Practice Address - Zip Code:33455-6085
Practice Address - Country:US
Practice Address - Phone:772-215-6156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW129563101YM0800X
FLSW12666101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACW018468OtherLICENSE NUMBER
FLSW12666OtherLICENSE NUMBER
FLSW12666OtherLCSW