Provider Demographics
NPI:1356994370
Name:TART, MICHAEL GORDON (LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GORDON
Last Name:TART
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 1:2577 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7813
Mailing Address - Country:US
Mailing Address - Phone:252-707-5075
Mailing Address - Fax:252-707-5285
Practice Address - Street 1:2577 W 5TH ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7813
Practice Address - Country:US
Practice Address - Phone:252-707-5075
Practice Address - Fax:252-707-5285
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0042481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical