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Individual
JAN MALLORY TATE
Active
Individual
JAN MALLORY TATE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LCSW, MED, CSOTP
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
C012511
NC
1041C0700X
Clinical Social Worker
Primary
C012511
NC
1041C0700X
Clinical Social Worker
P011313
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C012511
LCSW LICENSE NUMBER
NC
Enumeration date
09/28/2017
Last updated
10/18/2022
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