Provider Demographics
NPI:1598572869
Name:TATTOOED THERAPIST
Entity type:Organization
Organization Name:TATTOOED THERAPIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MOORE
Authorized Official - Last Name:ANDERTON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW, LCAS, LIC
Authorized Official - Phone:910-379-3412
Mailing Address - Street 1:1361 LOST NATION RD
Mailing Address - Street 2:
Mailing Address - City:NORTHUMBERLAND
Mailing Address - State:NH
Mailing Address - Zip Code:03582-4516
Mailing Address - Country:US
Mailing Address - Phone:910-379-3412
Mailing Address - Fax:
Practice Address - Street 1:1361 LOST NATION RD
Practice Address - Street 2:
Practice Address - City:NORTHUMBERLAND
Practice Address - State:NH
Practice Address - Zip Code:03582-4516
Practice Address - Country:US
Practice Address - Phone:910-379-3412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty