Provider Demographics
NPI:1053298307
Name:SHEPPARD, TARA (LCSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:SHEPPARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 BURNETT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-9004
Mailing Address - Country:US
Mailing Address - Phone:847-912-3573
Mailing Address - Fax:
Practice Address - Street 1:415 WASHINGTON ST STE 216S
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5564
Practice Address - Country:US
Practice Address - Phone:773-991-3983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490194281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty