Provider Demographics
NPI:1740259308
Name:WISDOM, TARA LEIGH (PT)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LEIGH
Last Name:WISDOM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:LEIGH
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3800 HULEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-7276
Mailing Address - Country:US
Mailing Address - Phone:512-876-8595
Mailing Address - Fax:
Practice Address - Street 1:3800 HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7276
Practice Address - Country:US
Practice Address - Phone:512-876-8595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1156069225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8FAV58OtherBLUE CROSS BLUE SHIELD
TX348440401Medicaid