Provider Demographics
NPI:1386342533
Name:FEARS, TARA NICHELLE (LPN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:NICHELLE
Last Name:FEARS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:N
Other - Last Name:FEARS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2156 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19121-1101
Mailing Address - Country:US
Mailing Address - Phone:215-530-4050
Mailing Address - Fax:
Practice Address - Street 1:2156 N 30TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121-1101
Practice Address - Country:US
Practice Address - Phone:215-397-7823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA284121164W00000X
101YA0400X, 101YM0800X, 175T00000X, 101YP2500X
PAPN284121164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist