=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821118530
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA L DAVIS CNP, LPCC-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 11/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 S MAIN ST STE 100
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-4283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-244-8782
-----------------------------------------------------
Fax | 330-244-8795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1201 S MAIN ST STE 100
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44720-4283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-244-8782
-----------------------------------------------------
Fax | 330-244-8795
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | E.0008189-SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.023645
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------