1841515939 NPI number — TARA BEAIRSTO MCCULLERS LCSW

Table of content: TARA BEAIRSTO MCCULLERS LCSW (NPI 1841515939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841515939 NPI number — TARA BEAIRSTO MCCULLERS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCULLERS
Provider First Name:
TARA
Provider Middle Name:
BEAIRSTO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841515939
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2073 OLYMPIC ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97477-3413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-682-3550
Provider Business Mailing Address Fax Number:
541-682-3551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1680 CHAMBERS ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97402-3655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-682-3550
Provider Business Practice Location Address Fax Number:
541-682-3551
Provider Enumeration Date:
03/31/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  080090 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: L5814 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)