MEDICARE: TARA WHITE 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	149.014295	IL

General Provider Information

NPI Number	:	1194111567
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA WHITE LCSW

Provider Business Mailing Address
First Line	:	1105 RAMONA TER
Second Line	:
City	:	MACHESNEY PARK
State	:	IL
Zip	:	61115-3843
Country	:	US
Telephone Number	:	815-621-5952
Fax Number	:

Provider Business Practice Location Address
First Line	:	6268 E RIVERSIDE BLVD
Second Line	:
City	:	LOVES PARK
State	:	IL
Zip	:	61111-4418
Country	:	US
Telephone Number	:	815-397-2224
Fax Number	:

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

Provider Enumeration Date	:	04/12/2015
Last Update Date	:	12/05/2018

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Directions to “ TARA WHITE LCSW” Practice Location

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