Provider Demographics
NPI:1144703570
Name:ROUSSEAU, TARA MULLAN (LICSW)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:MULLAN
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:KATHLEEN
Other - Last Name:MULLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1153 CENTRE ST STE 5J
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3446
Mailing Address - Country:US
Mailing Address - Phone:617-983-7300
Mailing Address - Fax:
Practice Address - Street 1:1153 CENTRE ST STE 5J
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1151501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical