Basic Information
| Provider Information | |||||||||
| NPI: | 1184918997 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TANGEN | ||||||||
| FirstName: | D'NICOLE | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 603949 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282603949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1962785079 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 23 SUNNYBROOK RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193507584 | ||||||||
| FaxNumber: | 9192310314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2011 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C012167 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1184918997 | 05 | NC | MEDICAID |