Provider Demographics
NPI:1790675171
Name:LEE, TARA (LICAC)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:LICAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 PENNSYLVANIA AVE, SUITE 115
Mailing Address - Street 2:#27
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64111
Mailing Address - Country:US
Mailing Address - Phone:828-284-5134
Mailing Address - Fax:
Practice Address - Street 1:482 MATHIS RD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28714-8147
Practice Address - Country:US
Practice Address - Phone:828-284-5134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC494171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist