Provider Demographics
NPI:1164295598
Name:WALLACE, TARA GRACE
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:GRACE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BIRCHTREE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02919-3545
Mailing Address - Country:US
Mailing Address - Phone:401-919-7233
Mailing Address - Fax:
Practice Address - Street 1:640 GEORGE WASHINGTON HWY
Practice Address - Street 2:SUITE B200
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865
Practice Address - Country:US
Practice Address - Phone:401-372-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health