Provider Demographics
NPI:1386168805
Name:PETERS, TARA JOY (LMSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:JOY
Last Name:PETERS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1513
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-0038
Mailing Address - Country:US
Mailing Address - Phone:631-487-4165
Mailing Address - Fax:
Practice Address - Street 1:1763 FERNSIDE DR
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-8095
Practice Address - Country:US
Practice Address - Phone:706-886-6521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker