Provider Demographics
NPI:1962179754
Name:THACKERAY, TARA LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:THACKERAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:GLOSHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1031 S BLUFF ST STE 225
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5206
Mailing Address - Country:US
Mailing Address - Phone:435-899-9668
Mailing Address - Fax:
Practice Address - Street 1:1031 S BLUFF ST STE 225
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5206
Practice Address - Country:US
Practice Address - Phone:435-899-9668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5863800-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical