Provider Demographics
NPI:1780202085
Name:NAYOWITH, TESSA BLAIR
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:BLAIR
Last Name:NAYOWITH
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 1:6512 SIX FORKS RD STE 403B
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6526
Mailing Address - Country:US
Mailing Address - Phone:919-591-0800
Mailing Address - Fax:
Practice Address - Street 1:6512 SIX FORKS RD STE 403B
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6526
Practice Address - Country:US
Practice Address - Phone:919-591-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15741101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health