Provider Demographics
NPI:1972655892
Name:PRINCE, DEIRDRE SELENE (MA CCAC)
Entity Type:Individual
Prefix:MS
First Name:DEIRDRE
Middle Name:SELENE
Last Name:PRINCE
Suffix:
Gender:F
Credentials:MA CCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 MISSION DR
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-5561
Mailing Address - Country:US
Mailing Address - Phone:304-485-1781
Mailing Address - Fax:304-485-1782
Practice Address - Street 1:1011 MISSION DR
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5561
Practice Address - Country:US
Practice Address - Phone:304-485-1781
Practice Address - Fax:304-485-1782
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVCREDENTIAL 99-306101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)