Provider Demographics
NPI:1669035267
Name:BOYER, TINA LATHAN (LCAS-A, LCMHCA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LATHAN
Last Name:BOYER
Suffix:
Gender:F
Credentials:LCAS-A, LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 PARK RD STE 218B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3650
Mailing Address - Country:US
Mailing Address - Phone:866-700-1606
Mailing Address - Fax:866-338-5921
Practice Address - Street 1:5200 PARK RD STE 218B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3650
Practice Address - Country:US
Practice Address - Phone:866-700-1606
Practice Address - Fax:866-338-5921
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20469101Y00000X, 101YA0400X
NCA17068101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional