=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710564067
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LA TANYA DENICE HARDY CADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2021
-----------------------------------------------------
Last Update Date | 03/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 714 S MAIN ST
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28144-5412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-495-3651
-----------------------------------------------------
Fax | 704-353-7901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2002 MISSION OAKS ST
-----------------------------------------------------
City | KANNAPOLIS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28083-7811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-983-0136
-----------------------------------------------------
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 | CADC-2792
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------