Provider Demographics
NPI:1447706999
Name:GORDEN, DARYL DAVID (MA, LCAS, LPC)
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:DAVID
Last Name:GORDEN
Suffix:
Gender:M
Credentials:MA, LCAS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR
Mailing Address - Street 2:STE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1831
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:227 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NC
Practice Address - Zip Code:27371-3058
Practice Address - Country:US
Practice Address - Phone:910-572-3681
Practice Address - Fax:910-572-5579
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22872101YA0400X
NCA12618101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1447706999Medicaid