Provider Demographics
NPI:1437424827
Name:EVANS, TABITHA (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 BLUE ROCK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-0624
Mailing Address - Country:US
Mailing Address - Phone:919-428-5313
Mailing Address - Fax:
Practice Address - Street 1:6600 ROCKY RIDGE RD
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NC
Practice Address - Zip Code:27278-7489
Practice Address - Country:US
Practice Address - Phone:919-428-5313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0073761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6009277Medicaid