Provider Demographics
NPI:1871718981
Name:MCCONKEY, TARA MELISSA (LICSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MELISSA
Last Name:MCCONKEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MELISSA
Other - Last Name:RUDSINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:82 POND ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4462
Mailing Address - Country:US
Mailing Address - Phone:401-365-6103
Mailing Address - Fax:
Practice Address - Street 1:82 POND ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4462
Practice Address - Country:US
Practice Address - Phone:401-365-6103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW017501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical