Provider Demographics
NPI:1215028741
Name:LONG-BANE, CAROLYN TYREASE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:TYREASE
Last Name:LONG-BANE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 DYKING RD
Mailing Address - Street 2:
Mailing Address - City:KITTRELL
Mailing Address - State:NC
Mailing Address - Zip Code:27544-8912
Mailing Address - Country:US
Mailing Address - Phone:757-536-7564
Mailing Address - Fax:919-570-3243
Practice Address - Street 1:1906 S MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-5033
Practice Address - Country:US
Practice Address - Phone:919-562-1080
Practice Address - Fax:919-570-3243
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040018301041C0700X
NCC0048101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical