Provider Demographics
NPI:1518412220
Name:GADDY, ROBERT MICHAEL JR (CSAC-I)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:GADDY
Suffix:JR
Gender:M
Credentials:CSAC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:NC
Mailing Address - Zip Code:28748-5646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:631 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:LEICESTER
Practice Address - State:NC
Practice Address - Zip Code:28748-5646
Practice Address - Country:US
Practice Address - Phone:828-318-0148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCSAC-20931101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC46-3813098OtherRED OAK RECOVERY