Healthcare Provider Details

I. General information

NPI: 1093247546
Provider Name (Legal Business Name): GARY LYNN MARSHALL LCASA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 SIGNAL HILL DRIVE EXT
STATESVILLE NC
28625-4391
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR STE 100
CONCORD NC
28025-1833
US

V. Phone/Fax

Practice location:
  • Phone: 704-873-1114
  • Fax: 704-873-9917
Mailing address:
  • Phone: 704-939-1100
  • Fax: 704-939-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number22508
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: