Provider Demographics
NPI:1851897409
Name:CONWAY, TIA WHEELER (LCSW)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:WHEELER
Last Name:CONWAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 NESTERS STORE PL SW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1235 NESTERS STORE PL SW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-8988
Practice Address - Country:US
Practice Address - Phone:803-792-7071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0122941041C0700X
NCC0133041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical