Provider Demographics
NPI:1497426787
Name:LACE, TATIM NEDY (LCSW-A)
Entity Type:Individual
Prefix:
First Name:TATIM
Middle Name:NEDY
Last Name:LACE
Suffix:
Gender:M
Credentials:LCSW-A
Other - Prefix:
Other - First Name:TATIM
Other - Middle Name:NEDY
Other - Last Name:BRACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 EAST BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4892
Mailing Address - Country:US
Mailing Address - Phone:980-477-0227
Mailing Address - Fax:704-980-3082
Practice Address - Street 1:700 EAST BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4892
Practice Address - Country:US
Practice Address - Phone:980-477-0227
Practice Address - Fax:704-980-3082
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-26
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0151091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical