Provider Demographics
NPI:1275989626
Name:ELMER, TAEGAN (MC, LAC)
Entity Type:Individual
Prefix:
First Name:TAEGAN
Middle Name:
Last Name:ELMER
Suffix:
Gender:F
Credentials:MC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 NORTHRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-3513
Mailing Address - Country:US
Mailing Address - Phone:520-869-5605
Mailing Address - Fax:
Practice Address - Street 1:29 NORTHRIDGE CIR
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-3513
Practice Address - Country:US
Practice Address - Phone:520-869-5605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-15774101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional