Provider Demographics
NPI:1235485871
Name:DIAGON THERAPUTIC LLC
Entity Type:Organization
Organization Name:DIAGON THERAPUTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MORROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-890-2192
Mailing Address - Street 1:296 SACCO ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-3059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:413 W MAIN AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-3896
Practice Address - Country:US
Practice Address - Phone:704-890-2192
Practice Address - Fax:704-974-6213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6115013Medicaid