Provider Demographics
NPI:1659702249
Name:DANIEL, TAWANNA KEOLA
Entity Type:Individual
Prefix:
First Name:TAWANNA
Middle Name:KEOLA
Last Name:DANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 W VANCROFT CIR APT 3
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-8086
Mailing Address - Country:US
Mailing Address - Phone:252-885-4370
Mailing Address - Fax:
Practice Address - Street 1:404 PALADIN DR APT N
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7864
Practice Address - Country:US
Practice Address - Phone:252-469-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-06
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0074391041C0700X
NCP0159851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical