Healthcare Provider Details

I. General information

NPI: 1295860344
Provider Name (Legal Business Name): TARA MICHELLE TIVNAN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ELM ST SUITE 102
WORCESTER MA
01609-1967
US

IV. Provider business mailing address

111 ELM ST SUITE 102
WORCESTER MA
01609-1967
US

V. Phone/Fax

Practice location:
  • Phone: 508-756-3750
  • Fax: 508-756-2729
Mailing address:
  • Phone: 508-756-3750
  • Fax: 508-756-2729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4803
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: