Basic Information
| Provider Information | |||||||||
| NPI: | 1497066120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANTLEY | ||||||||
| FirstName: | TENIKA | ||||||||
| MiddleName: | HOOKER | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2670 DURHAM CHAPEL HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277072829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192519001 | ||||||||
| FaxNumber: | 9192519010 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 HAY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104380939 | ||||||||
| FaxNumber: | 9104380942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2010 | ||||||||
| LastUpdateDate: | 11/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P012737 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 27-2767203 | 05 | NC | MEDICAID |