Provider Demographics
NPI:1174191597
Name:UNDERWOOD, TANESHA S (RN, CCM, LMBT)
Entity Type:Individual
Prefix:
First Name:TANESHA
Middle Name:S
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:RN, CCM, LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 BRAMBLEGATE RD
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-5733
Mailing Address - Country:US
Mailing Address - Phone:910-583-7321
Mailing Address - Fax:
Practice Address - Street 1:1018 BRAMBLEGATE RD
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348-5733
Practice Address - Country:US
Practice Address - Phone:910-583-7321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-13
Last Update Date:2021-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC233074163W00000X
NC4250206171M00000X
NC18343225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator