Provider Demographics
NPI:1659678647
Name:LUELLEN, TARA BETH (MA, LPA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:BETH
Last Name:LUELLEN
Suffix:
Gender:F
Credentials:MA, LPA
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:BETH
Other - Last Name:POOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:617 ANCIENT OAKS DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-7986
Mailing Address - Country:US
Mailing Address - Phone:573-888-7598
Mailing Address - Fax:919-346-1011
Practice Address - Street 1:5838 SIX FORKS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-3885
Practice Address - Country:US
Practice Address - Phone:919-785-9944
Practice Address - Fax:919-785-9992
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0935101YM0800X
NC4097103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health