Provider Demographics
NPI:1831625441
Name:LIASCHENKO, TAMARA (MA LCASA)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:LIASCHENKO
Suffix:
Gender:F
Credentials:MA LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5605
Mailing Address - Street 2:
Mailing Address - City:EMERALD ISLE
Mailing Address - State:NC
Mailing Address - Zip Code:28594-5605
Mailing Address - Country:US
Mailing Address - Phone:252-515-0557
Mailing Address - Fax:252-503-7399
Practice Address - Street 1:7901 EMERALD DR
Practice Address - Street 2:SUITE 15
Practice Address - City:EMERALD ISLE
Practice Address - State:NC
Practice Address - Zip Code:28594-2846
Practice Address - Country:US
Practice Address - Phone:252-515-0557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-23381101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)