Provider Demographics
NPI:1710011895
Name:MAGAW, TARA B (MA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:B
Last Name:MAGAW
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W OAK LEAF DR
Mailing Address - Street 2:# 18
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-4458
Mailing Address - Country:US
Mailing Address - Phone:262-617-7440
Mailing Address - Fax:
Practice Address - Street 1:6040 W LISBON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2116
Practice Address - Country:US
Practice Address - Phone:414-871-9111
Practice Address - Fax:414-871-9121
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI437-08-100Medicaid