Provider Demographics
NPI:1922687722
Name:CARSON, TINA L (LCSWA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:CARSON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 BRIDGEFIELD PLACE
Mailing Address - Street 2:#301
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216
Mailing Address - Country:US
Mailing Address - Phone:336-988-6644
Mailing Address - Fax:
Practice Address - Street 1:145 B SCALEYBARK ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209
Practice Address - Country:US
Practice Address - Phone:800-311-7072
Practice Address - Fax:704-662-0866
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPO158071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1922687722Medicaid