Provider Demographics
NPI:1427699511
Name:STREETMAN, TARA RENEE (LCSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:RENEE
Last Name:STREETMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 MEDFORD ST APT 514
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-1993
Mailing Address - Country:US
Mailing Address - Phone:210-859-4353
Mailing Address - Fax:
Practice Address - Street 1:172 NEWBURY ST
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-2405
Practice Address - Country:US
Practice Address - Phone:978-818-6235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224505104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker