Provider Demographics
NPI:1215005798
Name:ELLESTAD, TARA L (LPC)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:L
Last Name:ELLESTAD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7633 GANSER WAY STE 204
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-2092
Mailing Address - Country:US
Mailing Address - Phone:608-829-1800
Mailing Address - Fax:608-829-1885
Practice Address - Street 1:627 MAIN ST
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53530-1395
Practice Address - Country:US
Practice Address - Phone:608-776-4800
Practice Address - Fax:608-776-4914
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3453101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40966400Medicaid