Provider Demographics
NPI:1124897145
Name:TARA PETTIT DELOACH LLC
Entity type:Organization
Organization Name:TARA PETTIT DELOACH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:PETTIT
Authorized Official - Last Name:DELOACH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:706-343-3661
Mailing Address - Street 1:930 STEVENS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3200
Mailing Address - Country:US
Mailing Address - Phone:706-343-3661
Mailing Address - Fax:
Practice Address - Street 1:930 STEVENS CREEK RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-3200
Practice Address - Country:US
Practice Address - Phone:706-343-3661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health