Healthcare Provider Details

I. General information

NPI: 1538814009
Provider Name (Legal Business Name): TARA WHAREM LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 SARA RD SE STE 109
RIO RANCHO NM
87124-1524
US

IV. Provider business mailing address

PO BOX 45681
RIO RANCHO NM
87174-5681
US

V. Phone/Fax

Practice location:
  • Phone: 575-222-1650
  • Fax: 505-672-7769
Mailing address:
  • Phone: 505-226-1960
  • Fax: 505-672-7769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: TARA WHAREM
Title or Position: OWNER
Credential: LCSW
Phone: 575-222-1650