Healthcare Provider Details

I. General information

NPI: 1104601913
Provider Name (Legal Business Name): TYLER CONNIFEY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 TOWN CENTER DR STE 130
FAYETTEVILLE NC
28306-0049
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE WOMACK ARMY MEDICAL CENTER
FORT LIBERTY NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-212-6101
  • Fax:
Mailing address:
  • Phone: 910-907-8922
  • Fax: 910-907-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5095
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC019004
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number001084104
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: