Provider Demographics
NPI:1063031557
Name:SPADE, TARESA JANELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:TARESA
Middle Name:JANELLE
Last Name:SPADE
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 1:613 DIXON AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8623
Mailing Address - Country:US
Mailing Address - Phone:808-359-4730
Mailing Address - Fax:
Practice Address - Street 1:613 DIXON AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8623
Practice Address - Country:US
Practice Address - Phone:808-359-4730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-426561041C0700X
HILCSW-44931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical