Healthcare Provider Details

I. General information

NPI: 1801620059
Provider Name (Legal Business Name): TARA ALISON TIBBS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5211 AUTH RD STE 203
SUITLAND MD
20746-4339
US

IV. Provider business mailing address

14613 BLACKBURN RD
BURTONSVILLE MD
20866-1303
US

V. Phone/Fax

Practice location:
  • Phone: 202-257-6632
  • Fax:
Mailing address:
  • Phone: 240-938-0898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number28450
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: