Provider Demographics
NPI:1902372527
Name:WHACK, KANEISHA TIERRA (MS, CACP)
Entity Type:Individual
Prefix:
First Name:KANEISHA
Middle Name:TIERRA
Last Name:WHACK
Suffix:
Gender:F
Credentials:MS, CACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N HARVIN ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4956
Mailing Address - Country:US
Mailing Address - Phone:803-436-2462
Mailing Address - Fax:
Practice Address - Street 1:525 N LAFAYETTE DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4347
Practice Address - Country:US
Practice Address - Phone:803-436-2462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)