Provider Demographics
NPI:1104419530
Name:TAVARES, ANACLETO (BS)
Entity type:Individual
Prefix:
First Name:ANACLETO
Middle Name:
Last Name:TAVARES
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 KURLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-2651
Mailing Address - Country:US
Mailing Address - Phone:774-297-0492
Mailing Address - Fax:
Practice Address - Street 1:300 BATTLES ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2231
Practice Address - Country:US
Practice Address - Phone:774-297-0492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor