=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063023562
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAMARA GILARSKI, LCSW, RPT-S, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2020
-----------------------------------------------------
Last Update Date | 08/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1850 SW FOUNTAINVIEW BLVD
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-3443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-285-7245
-----------------------------------------------------
Fax | 772-340-7214
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 413 SW MAGNOLIA CV
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-2325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-285-7245
-----------------------------------------------------
Fax | 772-340-7214
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST, PLAY THERAPIST/SUP
-----------------------------------------------------
Name | MRS. TAMARA SUE GILARSKI
-----------------------------------------------------
Credential | LCSW, RPT-S
-----------------------------------------------------
Telephone | 772-285-7245
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------