=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508322884
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMMY JO SAMPSON-CHAVIS MA, LCAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2019
-----------------------------------------------------
Last Update Date | 07/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2003 GODWIN AVE
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28358-3149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-739-9063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 EASTWIND DR
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28358-6084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-316-5180
-----------------------------------------------------
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 | 23851
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------