Provider Demographics
NPI:1457690943
Name:MCDANIEL, TARA VIRGINIA (MA)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:VIRGINIA
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16314 HAYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4102
Mailing Address - Country:US
Mailing Address - Phone:704-509-1212
Mailing Address - Fax:
Practice Address - Street 1:416 MCCULLOUGH DR STE 230
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4395
Practice Address - Country:US
Practice Address - Phone:704-509-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9296101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health