Provider Demographics
NPI:1700359221
Name:DILLARD, TANISHA ANN
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:ANN
Last Name:DILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PAGE DR STE 7&8
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8847
Mailing Address - Country:US
Mailing Address - Phone:910-235-9090
Mailing Address - Fax:910-235-9093
Practice Address - Street 1:20 PAGE DR STE 7&8
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8847
Practice Address - Country:US
Practice Address - Phone:910-235-9090
Practice Address - Fax:910-235-9093
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23990101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)