Provider Demographics
NPI:1194860759
Name:DE VOSE, DELTON WADE (PHD, LPCS, CCS, BCTM)
Entity Type:Individual
Prefix:MR
First Name:DELTON
Middle Name:WADE
Last Name:DE VOSE
Suffix:
Gender:M
Credentials:PHD, LPCS, CCS, BCTM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 COLUMBIA RD STE 11B
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-0443
Mailing Address - Country:US
Mailing Address - Phone:919-937-5486
Mailing Address - Fax:888-445-2452
Practice Address - Street 1:4210 COLUMBIA RD STE 11B
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-0443
Practice Address - Country:US
Practice Address - Phone:706-364-6576
Practice Address - Fax:888-445-2452
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1658101YA0400X
NC4985101YP2500X
GA007674101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
3404922OtherBCBS
NC6103058Medicaid