Provider Demographics
NPI:1003187089
Name:BAYER, ILENE LILLIAN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ILENE
Middle Name:LILLIAN
Last Name:BAYER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1022
Mailing Address - Street 2:119-A N. CRUTCHFIELD STREET
Mailing Address - City:DOBSON
Mailing Address - State:NC
Mailing Address - Zip Code:27017-1022
Mailing Address - Country:US
Mailing Address - Phone:336-443-4116
Mailing Address - Fax:336-443-4092
Practice Address - Street 1:119-A N. CRUTCHFIELD STREET
Practice Address - Street 2:
Practice Address - City:DOBSON
Practice Address - State:NC
Practice Address - Zip Code:27017-1022
Practice Address - Country:US
Practice Address - Phone:336-443-4116
Practice Address - Fax:336-443-4092
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0076111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007433Medicaid
NCQ39633AOtherMEDICARE PTAN
NC12388384OtherCAQH