Healthcare Provider Details

I. General information

NPI: 1689921348
Provider Name (Legal Business Name): TARA L SNELL-KOOKEN MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2012
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 FAIR ST
BLOOMSBURG PA
17815-1419
US

IV. Provider business mailing address

320 HIGHLAND DR P.O. BOX 597
MOUNTVILLE PA
17554-1232
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6396
  • Fax:
Mailing address:
  • Phone: 717-285-7121
  • Fax: 717-285-2658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW127548
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW017679
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: