Provider Demographics
NPI:1265977342
Name:BANGTSON, TARA (LPCA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BANGTSON
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 E MAXWELL ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-2636
Mailing Address - Country:US
Mailing Address - Phone:859-255-0500
Mailing Address - Fax:
Practice Address - Street 1:251 E MAXWELL ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-2636
Practice Address - Country:US
Practice Address - Phone:859-255-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY170613101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor