Provider Demographics
NPI:1013321629
Name:ISAIAH, DERWIN SAMUEL II
Entity Type:Individual
Prefix:
First Name:DERWIN
Middle Name:SAMUEL
Last Name:ISAIAH
Suffix:II
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 1:1914 BRUNSWICK AVE STE 1B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1891
Mailing Address - Country:US
Mailing Address - Phone:704-281-6356
Mailing Address - Fax:
Practice Address - Street 1:1914 BRUNSWICK AVE STE 1B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1891
Practice Address - Country:US
Practice Address - Phone:704-281-6356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10304101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor