MEDICARE: TARA IVANOVITCH LCSW, LAC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	42	MT
2	1041C0700X	Clinical Social Worker	25403	MT

General Provider Information

NPI Number	:	1184081499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA IVANOVITCH LCSW, LAC

Provider Business Mailing Address
First Line	:	PO BOX 17962
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59808-7962
Country	:	US
Telephone Number	:	406-880-3123
Fax Number	:	844-500-6858

Provider Business Practice Location Address
First Line	:	2112 DIXON AVE STE 4
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-8226
Country	:	US
Telephone Number	:	406-880-3123
Fax Number	:	844-500-6858

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

Provider Enumeration Date	:	01/19/2016
Last Update Date	:	05/03/2024

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