Provider Demographics
NPI:1639505621
Name:STACK, TANIA JANEI (MSW, LCSW, CHC)
Entity Type:Individual
Prefix:
First Name:TANIA
Middle Name:JANEI
Last Name:STACK
Suffix:
Gender:F
Credentials:MSW, LCSW, CHC
Other - Prefix:
Other - First Name:TANIA
Other - Middle Name:JANEI
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:6305 ARSENAL AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-6780
Mailing Address - Country:US
Mailing Address - Phone:919-219-9747
Mailing Address - Fax:
Practice Address - Street 1:300 N GRACE ST
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-5345
Practice Address - Country:US
Practice Address - Phone:252-210-9856
Practice Address - Fax:252-822-5067
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0100961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical