Provider Demographics
NPI:1821225186
Name:GAINES, CYVONNE RUSH (LCAS)
Entity Type:Individual
Prefix:MRS
First Name:CYVONNE
Middle Name:RUSH
Last Name:GAINES
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148-C E MORGAN ST.
Mailing Address - Street 2:
Mailing Address - City:WADESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28170
Mailing Address - Country:US
Mailing Address - Phone:704-458-0130
Mailing Address - Fax:704-459-0130
Practice Address - Street 1:148-C E MORGAN ST.
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170
Practice Address - Country:US
Practice Address - Phone:704-458-0130
Practice Address - Fax:704-459-0130
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1375101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112112Medicaid