Provider Demographics
NPI:1235155177
Name:DEITCHMAN, ERIC L (PHD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:L
Last Name:DEITCHMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 ASHEVILLE PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6054
Mailing Address - Country:US
Mailing Address - Phone:704-344-0357
Mailing Address - Fax:704-364-5481
Practice Address - Street 1:417 S SHARON AMITY RD
Practice Address - Street 2:A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2868
Practice Address - Country:US
Practice Address - Phone:704-364-0452
Practice Address - Fax:704-364-5481
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0892103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC03421OtherBLUE CROSS BLUE SHIELD
NC03421OtherBLUE CROSS BLUE SHIELD