Provider Demographics
NPI:1508490467
Name:DEAVER, ELLA LEATHAM (MSW, LCAS-A LCSW-A)
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:LEATHAM
Last Name:DEAVER
Suffix:
Gender:F
Credentials:MSW, LCAS-A LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 OLEANDER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-4723
Mailing Address - Country:US
Mailing Address - Phone:910-208-6566
Mailing Address - Fax:
Practice Address - Street 1:5710 OLEANDER DR STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4723
Practice Address - Country:US
Practice Address - Phone:910-208-6566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-24306101YA0400X
NCP0140021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)