Provider Demographics
NPI:1457737991
Name:GAINES, MARIE I (LCSWA)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:I
Last Name:GAINES
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 HIDALGO DR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-5965
Mailing Address - Country:US
Mailing Address - Phone:910-495-5093
Mailing Address - Fax:
Practice Address - Street 1:511 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28312-5207
Practice Address - Country:US
Practice Address - Phone:910-897-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0098641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC17304OtherMEDICAID OPT
NC830223OtherMEDICAID GP