=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891472478
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAKERAH J MACON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2023
-----------------------------------------------------
Last Update Date | 07/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 943 W ANDREWS AVE
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27536-2516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-598-2462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 270 SHORE PINE DR
-----------------------------------------------------
City | YOUNGSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27596-7587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-885-7466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | P019705
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------