Provider Demographics
NPI:1346610110
Name:GREEN, TARA (MS CCC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 SAVANNAH RIDGE RD, SUITE 111
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-0535
Mailing Address - Country:US
Mailing Address - Phone:919-285-2157
Mailing Address - Fax:919-285-2157
Practice Address - Street 1:1140 SAVANNAH RIDGE RD, SUITE 111
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-0535
Practice Address - Country:US
Practice Address - Phone:919-285-2157
Practice Address - Fax:919-285-2157
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9266235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist