=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306132691
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA AMMERSEN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2011
-----------------------------------------------------
Last Update Date | 09/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 74 BUNNER ST
-----------------------------------------------------
City | OSWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13126-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-326-4167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 572 S SALINA ST
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13202-3320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-350-0192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 083530-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------