Basic Information
| Provider Information | |||||||||
| NPI: | 1114543295 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAL | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | CHAVIS | ||||||||
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| Credential: | LCSWA, LCASA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 LAUCHWOOD DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAURINBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102917000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5000 LAUNCHWOOD DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAURINBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102917000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2020 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 14655 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.