Provider Demographics
NPI:1790455111
Name:TAGARAM, ANNA GRACE (LCMHC)
Entity type:Individual
Prefix:
First Name:ANNA GRACE
Middle Name:
Last Name:TAGARAM
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 SIGNAL LN APT 1401
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-5415
Mailing Address - Country:US
Mailing Address - Phone:704-251-0086
Mailing Address - Fax:
Practice Address - Street 1:106 SIGNAL LN APT 1401
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-5415
Practice Address - Country:US
Practice Address - Phone:704-251-0086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16970101Y00000X, 101YP2500X
NC16970101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty