=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184158495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA GILDERSLEEVE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2017
-----------------------------------------------------
Last Update Date | 04/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 PROSPECT ST
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-3382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-673-6089
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 PROSPECT ST
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-3382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-673-6089
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R037088-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------