Provider Demographics
NPI:1558700336
Name:WILSON, TARA ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:NE
Mailing Address - Zip Code:69360-0779
Mailing Address - Country:US
Mailing Address - Phone:308-327-2026
Mailing Address - Fax:308-327-2126
Practice Address - Street 1:309 WEST 3
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:NE
Practice Address - Zip Code:69360-0779
Practice Address - Country:US
Practice Address - Phone:308-327-2026
Practice Address - Fax:308-327-2126
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9694101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional