Provider Demographics
NPI:1467553719
Name:QUEEN, DEIDRE S (MPT)
Entity Type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:S
Last Name:QUEEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10010 FALLS OF NEUSE RD
Mailing Address - Street 2:SUITE 015
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8494
Mailing Address - Country:US
Mailing Address - Phone:919-350-1508
Mailing Address - Fax:919-350-1475
Practice Address - Street 1:10010 FALLS OF NEUSE RD
Practice Address - Street 2:STE. 015
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8494
Practice Address - Country:US
Practice Address - Phone:919-350-1508
Practice Address - Fax:919-350-1475
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10272225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC079YUOtherBCBS OF NC
NC079YUOtherBCBS OF NC