1134316557 NPI number — FRANCES ERNESTINE TACK MS, LPC, LCAS, CCS

Table of content: KRISTEN BARNES (NPI 1700469475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134316557 NPI number — FRANCES ERNESTINE TACK MS, LPC, LCAS, CCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TACK
Provider First Name:
FRANCES
Provider Middle Name:
ERNESTINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC, LCAS, CCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TACK
Provider Other First Name:
FRANKIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, LPC, LCAS, CCS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1134316557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 35009
Provider Second Line Business Mailing Address:
BELK 3157
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28235-5009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-330-6749
Provider Business Mailing Address Fax Number:
704-330-6410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1335 ELIZABETH AVE.
Provider Second Line Business Practice Location Address:
BELK 3157
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28235-5009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-330-6749
Provider Business Practice Location Address Fax Number:
704-330-6410
Provider Enumeration Date:
09/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  LPC 2763 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: LCAS 675 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6102860 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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