Provider Demographics
NPI:1427009307
Name:DECONNA, PAUL (LCSW)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:DECONNA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 CLAYMORE DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-6448
Mailing Address - Country:US
Mailing Address - Phone:910-509-7212
Mailing Address - Fax:
Practice Address - Street 1:1213 CULBRETH DR
Practice Address - Street 2:SUITE 235
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3684
Practice Address - Country:US
Practice Address - Phone:910-509-7212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0028141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002198Medicaid
NC1017FOtherBLUE CROSS/BLUE SHIELD
NCIP463863OtherMAGELLAN
NCIP463863OtherMAGELLAN