Basic Information
Provider Information | |||||||||
NPI: | 1508336322 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DAYMARK RECOVERY SERVICES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 284 EXECUTIVE PARK DR STE 100 | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | NC | ||||||||
PostalCode: | 280251833 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7049391133 | ||||||||
FaxNumber: | 7049832636 | ||||||||
Practice Location | |||||||||
Address1: | 110 W WALKER AVE FL 3 | ||||||||
Address2: |   | ||||||||
City: | ASHEBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 272036760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3366337000 | ||||||||
FaxNumber: | 3366253817 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2018 | ||||||||
LastUpdateDate: | 03/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEST | ||||||||
AuthorizedOfficialFirstName: | BILLY | ||||||||
AuthorizedOfficialMiddleName: | RAY | ||||||||
AuthorizedOfficialTitleorPosition: | CEO,PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7049391133 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: | MSW,LCSW | ||||||||
NPICertificationDate: | 03/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   | 104100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.