Provider Demographics
NPI:1548478035
Name:GRAHAM, TARA (LICSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05408-2409
Mailing Address - Country:US
Mailing Address - Phone:802-881-3244
Mailing Address - Fax:802-654-7601
Practice Address - Street 1:20 W CANAL ST STE C2
Practice Address - Street 2:
Practice Address - City:WINOOSKI
Practice Address - State:VT
Practice Address - Zip Code:05404-2146
Practice Address - Country:US
Practice Address - Phone:802-448-4185
Practice Address - Fax:802-654-7601
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00011221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical