Provider Demographics
NPI:1043831639
Name:ELIZABETH A DEROUIN
Entity Type:Organization
Organization Name:ELIZABETH A DEROUIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ALEXANDRIA
Authorized Official - Last Name:DEROUIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-494-6000
Mailing Address - Street 1:422 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NC
Mailing Address - Zip Code:28658-3819
Mailing Address - Country:US
Mailing Address - Phone:910-494-6000
Mailing Address - Fax:
Practice Address - Street 1:422 W 9TH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NC
Practice Address - Zip Code:28658-3819
Practice Address - Country:US
Practice Address - Phone:910-494-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1275004111Medicaid