Provider Demographics
NPI:1780939355
Name:FAUNTLEROY, TATISHA DEVONNE (LCMHC)
Entity type:Individual
Prefix:
First Name:TATISHA
Middle Name:DEVONNE
Last Name:FAUNTLEROY
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 CALLANDALE LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-9803
Mailing Address - Country:US
Mailing Address - Phone:919-224-8896
Mailing Address - Fax:919-957-7375
Practice Address - Street 1:324 CALLANDALE LN
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-9803
Practice Address - Country:US
Practice Address - Phone:919-224-8896
Practice Address - Fax:919-957-7375
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8744101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health