MEDICARE: TOVAKYSHE WOULLARD LCSWA. LCAS-A

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	LCAS-26152	NC
2	1041C0700X	Clinical Social Worker	P014453	NC

General Provider Information

NPI Number	:	1174142277
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOVAKYSHE WOULLARD LCSWA. LCAS-A

Provider Business Mailing Address
First Line	:	4311 SCHOOL HOUSE CMNS # 174
Second Line	:
City	:	HARRISBURG
State	:	NC
Zip	:	28075-7510
Country	:	US
Telephone Number	:	704-639-2322
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 N CANNON BLVD # 106
Second Line	:
City	:	KANNAPOLIS
State	:	NC
Zip	:	28083-3798
Country	:	US
Telephone Number	:	980-206-3722
Fax Number	:

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

Provider Enumeration Date	:	04/09/2020
Last Update Date	:	09/29/2022

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