=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851897409
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIA WHEELER CONWAY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2018
-----------------------------------------------------
Last Update Date | 08/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1235 NESTERS STORE PL SW
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28027-8988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-792-7071
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1235 NESTERS STORE PL SW
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28027-8988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P012294
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C013304
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------