Provider Demographics
NPI:1871243378
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 1:2 PARAGON WAY STE 800
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-9573
Mailing Address - Country:US
Mailing Address - Phone:732-393-8391
Mailing Address - Fax:732-308-4500
Practice Address - Street 1:2 PARAGON WAY STE 800
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-9573
Practice Address - Country:US
Practice Address - Phone:732-393-8391
Practice Address - Fax:732-308-4500
Is Sole Proprietor?:No
Enumeration Date:2022-03-27
Last Update Date:2022-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00492700101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor