Provider Demographics
NPI:1255948196
Name:GADDY, MARCUS JAMAR (MSW LCSWA)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:JAMAR
Last Name:GADDY
Suffix:
Gender:M
Credentials:MSW LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5108 REAGAN DR STE 14
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-1395
Mailing Address - Country:US
Mailing Address - Phone:704-332-8787
Mailing Address - Fax:
Practice Address - Street 1:16325 NORTHCROSS DR STE F
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5044
Practice Address - Country:US
Practice Address - Phone:704-237-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP10470011041C0700X
NCPO1470011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty