Healthcare Provider Details

I. General information

NPI: 1194179291
Provider Name (Legal Business Name): TARA CANTRELL LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 FOGGY MOUNTAIN RD
HORSE SHOE NC
28742-9516
US

IV. Provider business mailing address

95 FOGGY MOUNTAIN RD
HORSE SHOE NC
28742-9516
US

V. Phone/Fax

Practice location:
  • Phone: 828-674-6411
  • Fax:
Mailing address:
  • Phone: 828-674-6411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA12036
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA12036
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: