Provider Demographics
NPI:1134603814
Name:XAYASOMLOTH, DEVIN MARTIE
Entity type:Individual
Prefix:
First Name:DEVIN
Middle Name:MARTIE
Last Name:XAYASOMLOTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 BACK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-2159
Mailing Address - Country:US
Mailing Address - Phone:448-263-0050
Mailing Address - Fax:
Practice Address - Street 1:1810 BACK CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213
Practice Address - Country:US
Practice Address - Phone:844-263-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW1120351041C0700X
NCC0134351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical