Provider Demographics
NPI:1124459912
Name:DILLARD ACADEMY
Entity type:Organization
Organization Name:DILLARD ACADEMY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:SCD
Authorized Official - Phone:404-806-0434
Mailing Address - Street 1:1602 STEPHENS ST
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-6720
Mailing Address - Country:US
Mailing Address - Phone:919-738-1206
Mailing Address - Fax:
Practice Address - Street 1:8014 CUMMING HWY
Practice Address - Street 2:SUITE 403302
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-9339
Practice Address - Country:US
Practice Address - Phone:404-806-0434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251300000XAgenciesLocal Education Agency (LEA)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8600110Medicaid