1659678647 NPI number — MRS. TARA BETH LUELLEN MA, LPA

Table of content: MRS. TARA BETH LUELLEN MA, LPA (NPI 1659678647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659678647 NPI number — MRS. TARA BETH LUELLEN MA, LPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUELLEN
Provider First Name:
TARA
Provider Middle Name:
BETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, LPA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POOL
Provider Other First Name:
TARA
Provider Other Middle Name:
BETH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659678647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5838 SIX FORKS RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27609-3885
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-785-9944
Provider Business Practice Location Address Fax Number:
919-785-9992
Provider Enumeration Date:
02/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  0935 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: 4097 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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