MEDICARE: TARA WHITECOTTON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149029547	IL

General Provider Information

NPI Number	:	1063394674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA WHITECOTTON LCSW

Provider Business Mailing Address
First Line	:	108 PEMBROKE RD SW
Second Line	:
City	:	POPLAR GROVE
State	:	IL
Zip	:	61065-9267
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 PEMBROKE RD SW
Second Line	:
City	:	POPLAR GROVE
State	:	IL
Zip	:	61065-9267
Country	:	US
Telephone Number	:	573-263-4987
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2025
Last Update Date	:	07/23/2025

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Directions to “ TARA WHITECOTTON LCSW” Practice Location

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