Provider Demographics
NPI:1821118530
Name:DAVIS, TARA L (CNP, LPCC-S)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CNP, LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-4283
Mailing Address - Country:US
Mailing Address - Phone:330-244-8782
Mailing Address - Fax:330-244-8795
Practice Address - Street 1:1201 S MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-4283
Practice Address - Country:US
Practice Address - Phone:330-244-8782
Practice Address - Fax:330-244-8795
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0008189-SUPV101YP2500X
OHAPRN.CNP.023645363LP0808X
OHRN.423945163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0315885Medicaid
OH11797385OtherPSYCHIATRY