Provider Demographics
NPI:1417354523
Name:STACK, TARA K (MSW, LCSW-C)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:K
Last Name:STACK
Suffix:
Gender:F
Credentials:MSW, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 ESTERS BLVD STE 900
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-2233
Mailing Address - Country:US
Mailing Address - Phone:415-424-4266
Mailing Address - Fax:415-520-6633
Practice Address - Street 1:16701 MELFORD BLVD STE 400
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4411
Practice Address - Country:US
Practice Address - Phone:415-424-4266
Practice Address - Fax:415-520-6633
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0280591041C0700X
MD19551104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD228022100Medicaid