=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356711246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY WAYNE GUY JR. LCASA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2015
-----------------------------------------------------
Last Update Date | 05/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 W 3RD AVE
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28052-4004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-285-4347
-----------------------------------------------------
Fax | 704-842-3874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1051 OBARR DR
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28054-6455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-980-2854
-----------------------------------------------------
Fax | 704-842-3874
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 21555
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------