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General NPI Number Information
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NPI Number | 1184081499
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Entity Type | Individual
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Provider Name | TARA IVANOVITCH LCSW, LAC
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Gender | Female
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Dates
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Enumeration Date | 01/19/2016
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Last Update Date | 05/03/2024
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Provider Practice Location Address
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Address Line | 2112 DIXON AVE STE 4
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City | MISSOULA
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State | MT
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Zip | 59801-8226
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Country | US
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Telephone | 406-880-3123
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Fax | 844-500-6858
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Provider Business Mailing Address
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Address Line | PO BOX 17962
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City | MISSOULA
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State | MT
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Zip | 59808-7962
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Country | US
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Telephone | 406-880-3123
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Fax | 844-500-6858
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 42
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License Number State | MT
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 25403
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License Number State | MT
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