Provider Demographics
NPI:1790002947
Name:DELOACH, TARA PETTIT (LMFT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:PETTIT
Last Name:DELOACH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:PETTIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:930 STEVENS CREEK RD STE 1
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3200
Mailing Address - Country:US
Mailing Address - Phone:706-343-3661
Mailing Address - Fax:
Practice Address - Street 1:930 STEVENS CREEK RD STE 1
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-3200
Practice Address - Country:US
Practice Address - Phone:706-343-3661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1313106H00000X
GAMFT001470106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist