Healthcare Provider Details

I. General information

NPI: 1841652765
Provider Name (Legal Business Name): TJA FAMILY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 N MADISON BLVD
ROXBORO NC
27573-5302
US

IV. Provider business mailing address

4613 BARN OWL CT
GREENSBORO NC
27406-8065
US

V. Phone/Fax

Practice location:
  • Phone: 336-558-4479
  • Fax:
Mailing address:
  • Phone: 336-558-4479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNC

VIII. Authorized Official

Name: LARISSA BOWLES ALSTON
Title or Position: MEMBER
Credential:
Phone: 336-558-4479