Provider Demographics
NPI:1598811002
Name:MRDJENOVIC, DONALD (CCS)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:
Last Name:MRDJENOVIC
Suffix:
Gender:M
Credentials:CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 ROCHELLE DR
Mailing Address - Street 2:APT. N-4
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-2664
Mailing Address - Country:US
Mailing Address - Phone:252-247-1109
Mailing Address - Fax:252-247-1107
Practice Address - Street 1:3820 BRIDGES ST
Practice Address - Street 2:STE B
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-2979
Practice Address - Country:US
Practice Address - Phone:252-648-3124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251101Y00000X, 101YA0400X
NCMHL-016-034251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6110564Medicaid