Provider Demographics
NPI:1114741873
Name:TATE, ELIANA LEATRICE
Entity type:Individual
Prefix:
First Name:ELIANA
Middle Name:LEATRICE
Last Name:TATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 EXECUTIVE PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5279
Mailing Address - Country:US
Mailing Address - Phone:919-480-1060
Mailing Address - Fax:
Practice Address - Street 1:592 EXECUTIVE PL
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5279
Practice Address - Country:US
Practice Address - Phone:919-480-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000048467424106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician