Provider Demographics
NPI:1760518856
Name:CLEVENGER, E DEVAULT
Entity Type:Individual
Prefix:MR
First Name:E
Middle Name:DEVAULT
Last Name:CLEVENGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 POPLARWOOD CT
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1084
Mailing Address - Country:US
Mailing Address - Phone:919-790-8580
Mailing Address - Fax:919-341-0231
Practice Address - Street 1:241 GRANT ST
Practice Address - Street 2:
Practice Address - City:WEST END
Practice Address - State:NC
Practice Address - Zip Code:27376
Practice Address - Country:US
Practice Address - Phone:910-673-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC185339OtherMED COST
NC22990OtherBCBS
NC6002228Medicaid