MEDICARE: FRANCES ERNESTINE TACK MS, LPC, LCAS, CCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	LPC 2763	NC
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCAS 675	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134316557
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FRANCES ERNESTINE TACK MS, LPC, LCAS, CCS

Provider Business Mailing Address
First Line	:	PO BOX 35009
Second Line	:	BELK 3157
City	:	CHARLOTTE
State	:	NC
Zip	:	28235-5009
Country	:	US
Telephone Number	:	704-330-6749
Fax Number	:	704-330-6410

Provider Business Practice Location Address
First Line	:	1335 ELIZABETH AVE.
Second Line	:	BELK 3157
City	:	CHARLOTTE
State	:	NC
Zip	:	28235-5009
Country	:	US
Telephone Number	:	704-330-6749
Fax Number	:	704-330-6410

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2007
Last Update Date	:	09/09/2010

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