Healthcare Provider Details

I. General information

NPI: 1710667274
Provider Name (Legal Business Name): TARA RAE TRESSLAR MED, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 07/20/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 MARKS CHURCH RD
AUGUSTA GA
30909-2670
US

IV. Provider business mailing address

424 KEELING LN
EVANS GA
30809-8227
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-5011
  • Fax:
Mailing address:
  • Phone: 317-502-7253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: