1053735142 NPI number — MS. REBECCA ANNE DEARDORFF LCSW

Table of content: MS. REBECCA ANNE DEARDORFF LCSW (NPI 1053735142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053735142 NPI number — MS. REBECCA ANNE DEARDORFF LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEARDORFF
Provider First Name:
REBECCA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053735142
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 GRASMERE COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LELAND
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-659-9422
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5041 NEW CENTRE DRIVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-567-6726
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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