Healthcare Provider Details

I. General information

NPI: 1043071731
Provider Name (Legal Business Name): WHITE TARA THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 CLARK RD
ELDRED NY
12732-5012
US

IV. Provider business mailing address

45 CLARK RD
ELDRED NY
12732-5012
US

V. Phone/Fax

Practice location:
  • Phone: 845-741-8898
  • Fax:
Mailing address:
  • Phone: 845-741-8898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILIP A ZUCKERMAN
Title or Position: OWNER
Credential:
Phone: 845-741-8898