Healthcare Provider Details

I. General information

NPI: 1013671080
Provider Name (Legal Business Name): TARA LEIGH SULLIVAN-BUTRICA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N CONGRESS AVE SUITE 301
WEST PALM BEACH FL
33407-2117
US

IV. Provider business mailing address

312 CEDARCROFT AVE
AUDUBON NJ
08106-2117
US

V. Phone/Fax

Practice location:
  • Phone: 856-454-3104
  • Fax:
Mailing address:
  • Phone: 215-594-9402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW021944
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: