Provider Demographics
NPI:1770281560
Name:WADE, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:WADE
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 1:19 WATER ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-1106
Mailing Address - Country:US
Mailing Address - Phone:513-843-3851
Mailing Address - Fax:513-938-1996
Practice Address - Street 1:19 WATER ST STE 2
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-1106
Practice Address - Country:US
Practice Address - Phone:513-843-3851
Practice Address - Fax:513-938-1996
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2400662-TEMP101YM0800X
OHC.2204350-TRNE390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00000OtherLICENSURE BOARD