Provider Demographics
NPI:1235291675
Name:VIRGIN, TELIA YEVETTE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TELIA
Middle Name:YEVETTE
Last Name:VIRGIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:TELIA
Other - Middle Name:YEVETTE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:111 WILLOWCROFT CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-7526
Mailing Address - Country:US
Mailing Address - Phone:919-841-3675
Mailing Address - Fax:919-779-4498
Practice Address - Street 1:111 WILLOWCROFT CT
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-7526
Practice Address - Country:US
Practice Address - Phone:919-841-3675
Practice Address - Fax:919-779-4498
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0052731041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106668Medicaid