Provider Demographics
NPI:1700091311
Name:ELDRIDGE, TARA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:ELDRIDGE
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 1:6645 VOOSCANE AVE
Mailing Address - Street 2:
Mailing Address - City:COCHITI LAKE
Mailing Address - State:NM
Mailing Address - Zip Code:87083-6003
Mailing Address - Country:US
Mailing Address - Phone:505-474-3095
Mailing Address - Fax:
Practice Address - Street 1:4730 BECKNER RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3691
Practice Address - Country:US
Practice Address - Phone:505-757-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-064291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM35074728Medicaid