Provider Demographics
NPI:1134545908
Name:BOSTIC, TAVARES (LCSW)
Entity type:Individual
Prefix:MR
First Name:TAVARES
Middle Name:
Last Name:BOSTIC
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 STROMAN RD
Mailing Address - Street 2:
Mailing Address - City:MARSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28363-9501
Mailing Address - Country:US
Mailing Address - Phone:585-967-8396
Mailing Address - Fax:
Practice Address - Street 1:102 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-4012
Practice Address - Country:US
Practice Address - Phone:910-642-7463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0100901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical