Basic Information
| Provider Information | |||||||||
| NPI: | 1255948196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GADDY | ||||||||
| FirstName: | MARCUS | ||||||||
| MiddleName: | JAMAR | ||||||||
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| Credential: | MSW LCSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5108 REAGAN DR STE 14 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282061395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043328787 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5108 REAGAN DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282063103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043328787 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2020 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | PO147001 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.