Healthcare Provider Details

I. General information

NPI: 1639016371
Provider Name (Legal Business Name): TARA N TAYLOR N TARA N TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 AVIATION CT
MCDONOUGH GA
30252-8712
US

IV. Provider business mailing address

1220 AVIATION CT
MCDONOUGH GA
30252-8712
US

V. Phone/Fax

Practice location:
  • Phone: 904-305-1698
  • Fax:
Mailing address:
  • Phone: 904-305-1698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMSW010753
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: