Provider Demographics
NPI:1790447142
Name:CARDWELL, TYISHA (LCSWA)
Entity Type:Individual
Prefix:
First Name:TYISHA
Middle Name:
Last Name:CARDWELL
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:TY
Other - Middle Name:
Other - Last Name:CARDWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSWA
Mailing Address - Street 1:1040 STILLWELL DR UNIT 4304
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-6285
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2011 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-1109
Practice Address - Country:US
Practice Address - Phone:919-238-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCSWA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical