Provider Demographics
NPI:1790025666
Name:WANAMAKER, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:WANAMAKER
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:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:CENTRAL VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10917-0368
Mailing Address - Country:US
Mailing Address - Phone:845-827-6227
Mailing Address - Fax:
Practice Address - Street 1:255 ROUTE 32
Practice Address - Street 2:
Practice Address - City:CENTRAL VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10917-3613
Practice Address - Country:US
Practice Address - Phone:845-827-6227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator