Provider Demographics
NPI:1154637585
Name:CENTER FOR FAMILY AND INDIVIDUAL GROWTH, PA
Entity Type:Organization
Organization Name:CENTER FOR FAMILY AND INDIVIDUAL GROWTH, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:336-786-7199
Mailing Address - Street 1:865 W LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-2157
Mailing Address - Country:US
Mailing Address - Phone:336-786-7199
Mailing Address - Fax:336-719-2313
Practice Address - Street 1:865 W LAKE DR
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2157
Practice Address - Country:US
Practice Address - Phone:336-786-7199
Practice Address - Fax:336-719-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0011901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1174YOtherBLUE CROSS BLUE SHIELD
NC308914OtherMAGELLAN
NC460508OtherVALUE OPTIONS
NC2031578OtherCIGNA
NC6002453Medicaid
NC6223730OtherUNITED HEALTH CARE
NCB5140OtherMEDCOST
NC2861999CMedicare PIN