Provider Demographics
NPI:1023557089
Name:OUILLETTE, TARA ASHLEY (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ASHLEY
Last Name:OUILLETTE
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 N MICHIGAN AVE STE 1830
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7407
Mailing Address - Country:US
Mailing Address - Phone:773-750-3505
Mailing Address - Fax:
Practice Address - Street 1:180 N MICHIGAN AVE STE 1830
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7407
Practice Address - Country:US
Practice Address - Phone:773-750-3505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI103K00000X
IL178011859101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1023557089Medicaid