Basic Information
| Provider Information | |||||||||
| NPI: | 1891910113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARRICK | ||||||||
| FirstName: | MADRIAN | ||||||||
| MiddleName: | GLOVER | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1023 FAIRFIELD CIR | ||||||||
| Address2: | |||||||||
| City: | RAEFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283766607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105503803 | ||||||||
| FaxNumber: | 9105503803 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 STAMPER RD STE G | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283034193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102237114 | ||||||||
| FaxNumber: | 9102230098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
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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 | C001600 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6106227 | 05 | NC | MEDICAID |