Provider Demographics
NPI:1386206654
Name:SPACH, TINA LONG (LCSW, LCAS)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LONG
Last Name:SPACH
Suffix:
Gender:F
Credentials:LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-713-0947
Mailing Address - Fax:
Practice Address - Street 1:791 JONESTOWN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1252
Practice Address - Country:US
Practice Address - Phone:336-716-4551
Practice Address - Fax:336-716-9694
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-25654101YA0400X
NCCO147801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC25654OtherLCAS-A LICENSE # 25654
NCP013799OtherLCSW-A LICENSE # P013799