Provider Demographics
NPI:1861630816
Name:BOSTON, DERIC J (LCSW)
Entity Type:Individual
Prefix:
First Name:DERIC
Middle Name:J
Last Name:BOSTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 IOWA LANE, SUITE 202
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511
Mailing Address - Country:US
Mailing Address - Phone:919-619-1032
Mailing Address - Fax:919-465-2307
Practice Address - Street 1:110 IOWA LANE, SUITE 202
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511
Practice Address - Country:US
Practice Address - Phone:919-619-1032
Practice Address - Fax:919-465-2307
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0060781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical