Healthcare Provider Details

I. General information

NPI: 1063176030
Provider Name (Legal Business Name): JELANI GAYLE-TENDAI MSW LCSW-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5418 GRAYPARK DR
CHARLOTTE NC
28269-5749
US

IV. Provider business mailing address

3814 12TH ST NE
WASHINGTON DC
20017-2630
US

V. Phone/Fax

Practice location:
  • Phone: 704-364-3989
  • Fax:
Mailing address:
  • Phone: 202-656-5095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP023254
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: