Provider Demographics
NPI:1356711246
Name:GUY, JERRY WAYNE JR (LCASA)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WAYNE
Last Name:GUY
Suffix:JR
Gender:M
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 CLANTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1309
Mailing Address - Country:US
Mailing Address - Phone:704-332-9001
Mailing Address - Fax:704-295-4937
Practice Address - Street 1:515 CLANTON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1309
Practice Address - Country:US
Practice Address - Phone:704-332-9001
Practice Address - Fax:704-295-4937
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21555101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)