Healthcare Provider Details

I. General information

NPI: 1154637585
Provider Name (Legal Business Name): CENTER FOR FAMILY AND INDIVIDUAL GROWTH, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 W LAKE DR
MOUNT AIRY NC
27030-2157
US

IV. Provider business mailing address

865 W LAKE DR
MOUNT AIRY NC
27030-2157
US

V. Phone/Fax

Practice location:
  • Phone: 336-786-7199
  • Fax: 336-719-2313
Mailing address:
  • Phone: 336-786-7199
  • Fax: 336-719-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC001190
License Number StateNC

VII. Legacy identifiers

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

# 1
Identifier1174Y
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBLUE CROSS BLUE SHIELD
# 2
Identifier308914
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerMAGELLAN
# 3
Identifier460508
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerVALUE OPTIONS
# 4
Identifier2031578
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerCIGNA
# 5
Identifier6002453
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 6
Identifier6223730
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerUNITED HEALTH CARE
# 7
IdentifierB5140
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerMEDCOST

VIII. Authorized Official

Name: MR. DARRELL THOMAS GARNER
Title or Position: PRESIDENT/PROVIDER
Credential: LCSW
Phone: 336-786-7199