MEDICARE: TARA GOGOLINSKI MS, LCMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	LCM514	MD

General Provider Information

NPI Number	:	1174867303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA GOGOLINSKI MS, LCMFT

Provider Business Mailing Address
First Line	:	2431 CROFTON LN STE 11
Second Line	:
City	:	CROFTON
State	:	MD
Zip	:	21114-1327
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2431 CROFTON LN
Second Line	:	SUITE 11
City	:	CROFTON
State	:	MD
Zip	:	21114-1327
Country	:	US
Telephone Number	:	410-793-7207
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2012
Last Update Date	:	09/29/2014

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