Provider Demographics
NPI:1649702739
Name:TRACEY TAYLOR CARTER
Entity type:Organization
Organization Name:TRACEY TAYLOR CARTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:706-284-2752
Mailing Address - Street 1:2703 BIG DOG TRL
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-4998
Mailing Address - Country:US
Mailing Address - Phone:706-284-2752
Mailing Address - Fax:
Practice Address - Street 1:1265 INTERSTATE PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6481
Practice Address - Country:US
Practice Address - Phone:706-284-2752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006844251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health