MEDICARE: TASHA L KORNEGAY PHD

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
2	101YM0800X	Mental Health Counselor
3	101YP2500X	Professional Counselor	7134	NC
4	101Y00000X	Counselor	S7134	NC

General Provider Information

NPI Number	:	1295986495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TASHA L KORNEGAY PHD

Provider Business Mailing Address
First Line	:	1702 SHERIFF WATSON RD
Second Line	:
City	:	SANFORD
State	:	NC
Zip	:	27332-6720
Country	:	US
Telephone Number	:	919-601-1313
Fax Number	:

Provider Business Practice Location Address
First Line	:	4909 WATERS EDGE DR
Second Line	:	SUITE 104
City	:	RALEIGH
State	:	NC
Zip	:	27606-2462
Country	:	US
Telephone Number	:	919-601-1313
Fax Number	:

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

Provider Enumeration Date	:	10/06/2008
Last Update Date	:	08/05/2022

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