1154840486 NPI number — MRS. DAVEISHA MERCEDES TANCK LCSWA

Table of content: MRS. DAVEISHA MERCEDES TANCK LCSWA (NPI 1154840486)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154840486 NPI number — MRS. DAVEISHA MERCEDES TANCK LCSWA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANCK
Provider First Name:
DAVEISHA
Provider Middle Name:
MERCEDES
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSWA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154840486
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7943 ROLLING MEADOWS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTERSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28078-3349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-317-2777
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
919 N MAIN ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28115-2355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-317-2777
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2017

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: 1041C0700X , with the licence number:  C012880 , 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)





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