Provider Demographics
NPI:1114342904
Name:MCDONALD, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:CASTLE HAYNE
Mailing Address - State:NC
Mailing Address - Zip Code:28429-0509
Mailing Address - Country:US
Mailing Address - Phone:910-791-5757
Mailing Address - Fax:910-251-5893
Practice Address - Street 1:2202 WRIGHTSVILLE AVE
Practice Address - Street 2:STE 113
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-3051
Practice Address - Country:US
Practice Address - Phone:910-791-5757
Practice Address - Fax:910-251-5893
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-03
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6008126Medicaid