Basic Information
| Provider Information | |||||||||
| NPI: | 1710057476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEATTY | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BEATTY | ||||||||
| OtherFirstName: | DANIEL | ||||||||
| OtherMiddleName: | RICHARD | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 219A AVERY AVE | ||||||||
| Address2: | |||||||||
| City: | MORGANTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286553102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284308344 | ||||||||
| FaxNumber: | 8284304384 | ||||||||
| Practice Location | |||||||||
| Address1: | 219A AVERY AVE | ||||||||
| Address2: | |||||||||
| City: | MORGANTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286553102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284308344 | ||||||||
| FaxNumber: | 8284304384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 08/29/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | C004809 | NC | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | C004809 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6003109 | 05 | NC | MEDICAID |