Provider Demographics
NPI:1124854773
Name:ROOT, TAVIS CONNOR (LPC)
Entity type:Individual
Prefix:MR
First Name:TAVIS
Middle Name:CONNOR
Last Name:ROOT
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HEYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1706
Mailing Address - Country:US
Mailing Address - Phone:606-793-1398
Mailing Address - Fax:
Practice Address - Street 1:3211 REIDVILLE RD STE C
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-6120
Practice Address - Country:US
Practice Address - Phone:864-278-0593
Practice Address - Fax:864-586-2300
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10170101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health