Provider Demographics
NPI:1972131100
Name:WISE, TARA JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JEAN
Last Name:WISE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:J
Other - Last Name:CHAPDELAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5 NEPONSET ST FL STREET2
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-856-0732
Mailing Address - Fax:508-425-5126
Practice Address - Street 1:1 EATON PL
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1232
Practice Address - Country:US
Practice Address - Phone:508-856-0732
Practice Address - Fax:508-425-5126
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2245181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical