MEDICARE: MT AIRY THERAPY & CONSULTING SERVICES, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1386424141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MT AIRY THERAPY & CONSULTING SERVICES, PLLC

Provider Business Mailing Address
First Line	:	1022 N MAIN ST
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-3636
Country	:	US
Telephone Number	:	336-909-0192
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 N MAIN ST
Second Line	:
City	:	MOUNT AIRY
State	:	NC
Zip	:	27030-3810
Country	:	US
Telephone Number	:	336-909-0192
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALAN GREGORY BAGSHAW
Credential	:	LCSW LCAS
Telephone Number	:	336-909-0192

Provider Enumeration Date	:	09/29/2023
Last Update Date	:	10/04/2023

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