Healthcare Provider Details

I. General information

NPI: 1386298628
Provider Name (Legal Business Name): TABER CARLSON MA, LPC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 CRABAPPLE CIR
WATKINSVILLE GA
30677-4123
US

IV. Provider business mailing address

PO BOX 425
WATKINSVILLE GA
30677-0011
US

V. Phone/Fax

Practice location:
  • Phone: 605-641-7328
  • Fax:
Mailing address:
  • Phone: 605-641-7328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC3340A
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC04543
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: