Healthcare Provider Details

I. General information

NPI: 1407691751
Provider Name (Legal Business Name): TARA THOMPSON LMT,CD,CBE,CPD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 12/22/2024
Certification Date: 12/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4390 BELLS FERRY RD NW
KENNESAW GA
30144-1354
US

IV. Provider business mailing address

207 BROOKHAVEN CT
ACWORTH GA
30102-2190
US

V. Phone/Fax

Practice location:
  • Phone: 770-380-6364
  • Fax:
Mailing address:
  • Phone: 770-380-6364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT003160
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: