Provider Demographics
NPI:1306415294
Name:GAULT, TANYA (LAC)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:GAULT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 BRICKYARD POINT RD S
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29907-1232
Mailing Address - Country:US
Mailing Address - Phone:404-431-4814
Mailing Address - Fax:
Practice Address - Street 1:1108 CHARLES ST UNIT B
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-4501
Practice Address - Country:US
Practice Address - Phone:843-279-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC310171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC310OtherBOARD OF MEDICAL EXAMINERS - ACUPUNCTURIST
169942OtherNCCAOM