Healthcare Provider Details

I. General information

NPI: 1154908085
Provider Name (Legal Business Name): TARA FREY RSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

988 N ILLINOIS ROUTE 3
WATERLOO IL
62298-1059
US

IV. Provider business mailing address

988 N ILLINOIS ROUTE 3
WATERLOO IL
62298-1059
US

V. Phone/Fax

Practice location:
  • Phone: 618-939-4444
  • Fax:
Mailing address:
  • Phone: 618-939-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37711
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: