Provider Demographics
NPI:1174688733
Name:DESOTO, ROBERT LYNN (LCSW, BCD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LYNN
Last Name:DESOTO
Suffix:
Gender:M
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2070 MARES WAY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-7940
Mailing Address - Country:US
Mailing Address - Phone:252-355-0160
Mailing Address - Fax:
Practice Address - Street 1:925 CONFERENCE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5971
Practice Address - Country:US
Practice Address - Phone:252-756-4899
Practice Address - Fax:252-756-5141
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0005141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC28428OtherBCBS PROVIDER NUMBER
NC6002068Medicaid
NC6002068Medicaid