=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407496441
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA J BENIGNO LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2020
-----------------------------------------------------
Last Update Date | 01/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 70 PARK ST STE 104
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-2960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-248-4442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 FRANKLIN AVE
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07040-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-757-4803
-----------------------------------------------------
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 | 44SL06540600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------