Provider Demographics
NPI:1619506367
Name:LINEBERRY, TARA BREWSTER (LCSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:BREWSTER
Last Name:LINEBERRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 W MAIN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2304
Mailing Address - Country:US
Mailing Address - Phone:276-200-4521
Mailing Address - Fax:
Practice Address - Street 1:180 W MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2304
Practice Address - Country:US
Practice Address - Phone:276-200-4521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-05
Last Update Date:2023-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178041363LP0808X
VA09040110101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty