Provider Demographics
NPI:1013715234
Name:WISDOM, TAZIA (PCLC)
Entity type:Individual
Prefix:
First Name:TAZIA
Middle Name:
Last Name:WISDOM
Suffix:
Gender:F
Credentials:PCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 3RD AVE E
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-4907
Mailing Address - Country:US
Mailing Address - Phone:504-357-1773
Mailing Address - Fax:
Practice Address - Street 1:1035 1ST AVE W STE 210
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-5607
Practice Address - Country:US
Practice Address - Phone:504-357-1773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-50455101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health