MEDICARE: MRS. TARA BETH LUELLEN MA, LPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	0935	KY
2	103TC0700X	Clinical Psychologist	4097	NC

General Provider Information

NPI Number	:	1659678647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TARA BETH LUELLEN MA, LPA

Provider Business Mailing Address
First Line	:	617 ANCIENT OAKS DR
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-7986
Country	:	US
Telephone Number	:	573-888-7598
Fax Number	:	919-346-1011

Provider Business Practice Location Address
First Line	:	5838 SIX FORKS RD
Second Line	:	SUITE 200
City	:	RALEIGH
State	:	NC
Zip	:	27609-3885
Country	:	US
Telephone Number	:	919-785-9944
Fax Number	:	919-785-9992

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2011
Last Update Date	:	04/03/2012

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