=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770281560
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA WADE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2023
-----------------------------------------------------
Last Update Date | 05/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 WATER ST STE 2
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45150-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-843-3851
-----------------------------------------------------
Fax | 513-938-1996
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 WATER ST STE 2
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45150-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-843-3851
-----------------------------------------------------
Fax | 513-938-1996
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | C.2400662-TEMP
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | C.2204350-TRNE
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------