Provider Demographics
NPI:1417452665
Name:SOLDANO-DAVIS, TARA M (MA, LPC-A)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:SOLDANO-DAVIS
Suffix:
Gender:F
Credentials:MA, LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11023 ROYAL COLONY DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6783
Mailing Address - Country:US
Mailing Address - Phone:704-256-9302
Mailing Address - Fax:
Practice Address - Street 1:11023 ROYAL COLONY DR
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6783
Practice Address - Country:US
Practice Address - Phone:704-256-9302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13858101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCA13858OtherLPC-A