Provider Demographics
NPI:1356762207
Name:DILLARD ACADEMY
Entity type:Organization
Organization Name:DILLARD ACADEMY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADVISOR
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:919-581-0166
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:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96C251300000X
NC8600110251B00000X, 251V00000X, 252Y00000X, 251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No251V00000XAgenciesVoluntary or Charitable
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8600110Medicaid