Healthcare Provider Details

I. General information

NPI: 1205269206
Provider Name (Legal Business Name): ILENE LILLIAN BAYER LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 N CRUTCHFIELD ST
DOBSON NC
27017-8804
US

IV. Provider business mailing address

PO BOX 1022 119 A N CRUTCHFIELD STREET
DOBSON NC
27017-1022
US

V. Phone/Fax

Practice location:
  • Phone: 336-443-4116
  • Fax: 336-443-4092
Mailing address:
  • Phone: 336-443-4116
  • Fax: 336-443-4092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC00761
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6007433
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MS. ILENE LILLIAN BAYER
Title or Position: SOLE PRACTITIONER
Credential: LCSW
Phone: 336-443-4116