Provider Demographics
NPI:1487037404
Name:WAGNER, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:WAGNER
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 1:6318 RICHMOND AVE UNIT 4201
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-3692
Mailing Address - Country:US
Mailing Address - Phone:903-312-8397
Mailing Address - Fax:
Practice Address - Street 1:6318 RICHMOND AVE UNIT 4201
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-3692
Practice Address - Country:US
Practice Address - Phone:903-312-8397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11518882103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst