MEDICARE: SUPRENA TARVER 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	34008371A	IN

General Provider Information

NPI Number	:	1477025476
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUPRENA TARVER LCSW

Provider Business Mailing Address
First Line	:	3835 HORNICKEL DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46235-3621
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3835 HORNICKEL DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46235-3621
Country	:	US
Telephone Number	:	317-956-0707
Fax Number	:

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

Provider Enumeration Date	:	01/02/2019
Last Update Date	:	02/18/2020

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