Provider Demographics
NPI:1043633027
Name:WALLACE, TARA
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:WALLACE
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 1:325 SW FRAZIER AVE
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1963
Mailing Address - Country:US
Mailing Address - Phone:785-232-5005
Mailing Address - Fax:
Practice Address - Street 1:225 SW 12TH ST RM 205
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66612-1310
Practice Address - Country:US
Practice Address - Phone:785-633-9453
Practice Address - Fax:785-727-4006
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9072104100000X
KS47411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker