Provider Demographics
NPI:1972081586
Name:PRINS, TANISHA NEDELKA (LCSW, BCD)
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:NEDELKA
Last Name:PRINS
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1736 CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23523-2308
Mailing Address - Country:US
Mailing Address - Phone:224-381-2479
Mailing Address - Fax:
Practice Address - Street 1:1800 DONG XOAI AVENUE
Practice Address - Street 2:BUILDING 60, ROOM 250
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:224-381-2479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0132481041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical