Healthcare Provider Details

I. General information

NPI: 1033505698
Provider Name (Legal Business Name): TARA ROBERTS L.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 04/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 BIRCH ST
BLOOMFIELD NJ
07003-4047
US

IV. Provider business mailing address

85 BIRCH ST
BLOOMFIELD NJ
07003-4047
US

V. Phone/Fax

Practice location:
  • Phone: 973-517-4575
  • Fax: 973-762-5610
Mailing address:
  • Phone: 973-517-4575
  • Fax: 973-762-5610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SLO5462400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: