Basic Information
Provider Information | |||||||||
NPI: | 1407151806 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEBSTER | ||||||||
FirstName: | TARA | ||||||||
MiddleName: | LEIGH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CLENDANIEL | ||||||||
OtherFirstName: | TARA | ||||||||
OtherMiddleName: | LEIGH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LGSW | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2336 GODDARD PKWY | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218011126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103346961 | ||||||||
FaxNumber: | 4103346362 | ||||||||
Practice Location | |||||||||
Address1: | 2336 GODDARD PKWY | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218011126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103346961 | ||||||||
FaxNumber: | 4103346362 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/14/2011 | ||||||||
LastUpdateDate: | 02/22/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 19058 | MD | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 101YA0400X | SC1659 | MD | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 19058 | MD | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 259147-000 | 01 | MD | MAGELLAN BEHAVIORAL HEALTH | OTHER | 517251 | 01 | MD | OPTUM/UBH | OTHER | 346646 | 01 | MD | MHN/TRICARE | OTHER | 7840093. | 01 | MD | AETNA | OTHER | 520202700 | 05 | MD |   | MEDICAID | R968 | 01 | MD | CAREFIRST | OTHER | 609550001 | 05 | MD |   | MEDICAID |