Basic Information
| Provider Information | |||||||||
| NPI: | 1760515688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DROZDA | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BANES CRAIG NELSON | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | DIANE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1503 SUITE E WAYNE MEMORIAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275342203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195870001 | ||||||||
| FaxNumber: | 9195870007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1503 WAYNE MEMORIAL DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275342203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195870001 | ||||||||
| FaxNumber: | 9195870007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 08/19/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I-06561 | NM | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | C008197 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 34280081 | 05 | NM | MEDICAID |