Basic Information
| Provider Information | |||||||||
| NPI: | 1043797020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'NEIL | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | CONCETTA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 28 SAVOY ST | ||||||||
| Address2: | |||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065143511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036063226 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1046 FAIRFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066051116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033306000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2018 | ||||||||
| LastUpdateDate: | 08/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 4330 | CT | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 011103 | CT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.