Provider Demographics
NPI:1912721804
Name:TAVERA, GERARDO (LMSW)
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:
Last Name:TAVERA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-4604
Mailing Address - Country:US
Mailing Address - Phone:181-570-5312
Mailing Address - Fax:
Practice Address - Street 1:914 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-4604
Practice Address - Country:US
Practice Address - Phone:815-570-5312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD323411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical