Provider Demographics
NPI:1295986495
Name:KORNEGAY, TASHA L (PHD)
Entity type:Individual
Prefix:
First Name:TASHA
Middle Name:L
Last Name:KORNEGAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 SHERIFF WATSON RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-6720
Mailing Address - Country:US
Mailing Address - Phone:919-601-1313
Mailing Address - Fax:
Practice Address - Street 1:4909 WATERS EDGE DR
Practice Address - Street 2:SUITE 104
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-2462
Practice Address - Country:US
Practice Address - Phone:919-601-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
NC7134101YP2500X
NCS7134101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty