Provider Demographics
NPI:1023412558
Name:ELIJAH, TYRONE (LCSWA)
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:ELIJAH
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 CHELTENHAM DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2534
Mailing Address - Country:US
Mailing Address - Phone:252-917-3720
Mailing Address - Fax:
Practice Address - Street 1:216 STEWART PKWY
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-4972
Practice Address - Country:US
Practice Address - Phone:252-946-0585
Practice Address - Fax:252-946-0580
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24366101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty