Provider Demographics
NPI:1265823611
Name:MCKOY-SUTTON, TANYA (LCAS-A)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MCKOY-SUTTON
Suffix:
Gender:F
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 PENNCROSS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-6065
Mailing Address - Country:US
Mailing Address - Phone:919-931-2704
Mailing Address - Fax:
Practice Address - Street 1:2000 YONKERS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-2258
Practice Address - Country:US
Practice Address - Phone:919-931-2704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21154101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)