Provider Demographics
NPI:1568818706
Name:WOOTEN, TARA (LPC)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:
Last Name:WOOTEN
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 1:720 MAGNOLIA RD STE 8
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7094
Mailing Address - Country:US
Mailing Address - Phone:843-276-3977
Mailing Address - Fax:
Practice Address - Street 1:720 MAGNOLIA RD STE 8
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7094
Practice Address - Country:US
Practice Address - Phone:843-276-3977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC6363101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health