Provider Demographics
NPI:1063107472
Name:FIELDS (TJ), TYRONE JERROD (NCCPSS, CADC-R)
Entity type:Individual
Prefix:MR
First Name:TYRONE
Middle Name:JERROD
Last Name:FIELDS (TJ)
Suffix:
Gender:M
Credentials:NCCPSS, CADC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7317 MELISSA CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5814
Mailing Address - Country:US
Mailing Address - Phone:678-270-7112
Mailing Address - Fax:
Practice Address - Street 1:3427 MELROSE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-1608
Practice Address - Country:US
Practice Address - Phone:910-864-8739
Practice Address - Fax:910-864-8222
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCADC-28086101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)