Provider Demographics
NPI:1275086480
Name:ANCRUM, TARA D (LPC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:D
Last Name:ANCRUM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5740 ANCRUM BUTLER LN
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29449-7101
Mailing Address - Country:US
Mailing Address - Phone:843-437-0372
Mailing Address - Fax:
Practice Address - Street 1:5740 ANCRUM BUTLER LN
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:SC
Practice Address - Zip Code:29449-7101
Practice Address - Country:US
Practice Address - Phone:843-437-0372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6589101YM0800X, 101YP2500X
SC6126101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC435201Medicaid
SC435201Medicaid