Basic Information
| Provider Information | |||||||||
| NPI: | 1154637585 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTER FOR FAMILY AND INDIVIDUAL GROWTH, PA | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 865 W LAKE DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270302157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367867199 | ||||||||
| FaxNumber: | 3367192313 | ||||||||
| Practice Location | |||||||||
| Address1: | 865 W LAKE DR | ||||||||
| Address2: | |||||||||
| City: | MOUNT AIRY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270302157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367867199 | ||||||||
| FaxNumber: | 3367192313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2010 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARNER | ||||||||
| AuthorizedOfficialFirstName: | DARRELL | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 3367867199 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C001190 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1174Y | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 308914 | 01 | NC | MAGELLAN | OTHER | 460508 | 01 | NC | VALUE OPTIONS | OTHER | 2031578 | 01 | NC | CIGNA | OTHER | 6002453 | 05 | NC | MEDICAID | 6223730 | 01 | NC | UNITED HEALTH CARE | OTHER | B5140 | 01 | NC | MEDCOST | OTHER |