Healthcare Provider Details

I. General information

NPI: 1174153126
Provider Name (Legal Business Name): TARA ALESIA TAYLOR MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 RONNIE CT STE C
MYRTLE BEACH SC
29579-4204
US

IV. Provider business mailing address

PO BOX 16091
SURFSIDE BEACH SC
29587-6091
US

V. Phone/Fax

Practice location:
  • Phone: 843-894-0000
  • Fax:
Mailing address:
  • Phone: 843-894-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7716
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7716
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: