Provider Demographics
NPI:1477441624
Name:DERSE, JAMES (LCMHCA)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:DERSE
Suffix:
Gender:M
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 HATCHER RD
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:NC
Mailing Address - Zip Code:27576-7741
Mailing Address - Country:US
Mailing Address - Phone:920-627-9099
Mailing Address - Fax:
Practice Address - Street 1:10580 LIGON MILL RD STE 210
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6090
Practice Address - Country:US
Practice Address - Phone:919-263-9592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA21604101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health