Provider Demographics
NPI:1992750178
Name:BLACKARD COOK, TAMMY (LCSW)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:BLACKARD COOK
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 1:120 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-1718
Mailing Address - Country:US
Mailing Address - Phone:919-272-6854
Mailing Address - Fax:919-832-3449
Practice Address - Street 1:1330 SAINT MARYS ST
Practice Address - Street 2:SUITE 340
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1375
Practice Address - Country:US
Practice Address - Phone:919-272-6854
Practice Address - Fax:919-832-3449
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0040591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007268Medicaid
NC017WXOtherBCBS GROUP NUMBER
NC131UEOtherBCBS PROVIDER #