Provider Demographics
NPI:1487027009
Name:WEDEMEYER, TARA (MS, LPC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:WEDEMEYER
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 CEDAR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-7052
Mailing Address - Country:US
Mailing Address - Phone:940-390-4742
Mailing Address - Fax:
Practice Address - Street 1:805 E 1ST ST
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-2919
Practice Address - Country:US
Practice Address - Phone:940-390-4742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70401101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional