Provider Demographics
NPI:1952409294
Name:COPPOLA, TARA ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ANNE
Last Name:COPPOLA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 DEER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-6273
Mailing Address - Country:US
Mailing Address - Phone:678-488-1476
Mailing Address - Fax:678-606-9316
Practice Address - Street 1:4006 HOLCOMB BRIDGE RD STE 210
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-1814
Practice Address - Country:US
Practice Address - Phone:678-444-4505
Practice Address - Fax:678-606-9316
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0030581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA233399379AMedicaid