Provider Demographics
NPI:1205018355
Name:JAMES, TANISHA R (LCSW)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:R
Last Name:JAMES
Suffix:
Gender:F
Credentials:LCSW
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 25238
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5003
Mailing Address - Country:US
Mailing Address - Phone:704-726-1270
Mailing Address - Fax:866-462-1782
Practice Address - Street 1:351 WAGONER DR
Practice Address - Street 2:SUITE 310
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4608
Practice Address - Country:US
Practice Address - Phone:910-475-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0057931041C0700X
SC92951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106806Medicaid