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General NPI Number Information
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NPI Number | 1720656291
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Entity Type | Individual
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Provider Name | TARAKA TAYLOR-MOULTRIE LISW-CP
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Gender | Female
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Dates
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Enumeration Date | 06/11/2021
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Last Update Date | 06/11/2021
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Provider Practice Location Address
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Address Line | 780 CHARTER DR UNIT B11
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City | LONGS
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State | SC
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Zip | 29568-5833
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Country | US
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Telephone | 478-361-2126
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Fax |
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Provider Business Mailing Address
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Address Line | 780 CHARTER DR UNIT B11
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City | LONGS
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State | SC
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Zip | 29568-5833
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Country | US
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Telephone | 478-361-2126
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 14372
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License Number State | SC
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