=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316599160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYEASIA K DORSEY CSAC, LCAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2019
-----------------------------------------------------
Last Update Date | 02/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 E PITT ST STE 103
-----------------------------------------------------
City | TARBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27886-5137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-378-9940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2054 FISHPOND RD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27834-8852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-814-5095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 14234
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number | 21899
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 21899
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------