Provider Demographics
NPI:1629020003
Name:PROFFITT, DEBORAH HALL (MA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:HALL
Last Name:PROFFITT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 TANGLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1646
Mailing Address - Country:US
Mailing Address - Phone:704-442-1656
Mailing Address - Fax:704-442-1656
Practice Address - Street 1:4425 RANDOLPH RD
Practice Address - Street 2:SUITE 206
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2348
Practice Address - Country:US
Practice Address - Phone:704-609-4006
Practice Address - Fax:704-442-1656
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2443103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2443OtherLICENSE- PSYCHOLOGICAL A.