Provider Demographics
NPI:1265620611
Name:DAVIS, DERRICK LAVEL SR (LPC)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:LAVEL
Last Name:DAVIS
Suffix:SR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 563328
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28256-3328
Mailing Address - Country:US
Mailing Address - Phone:704-449-1750
Mailing Address - Fax:704-730-8040
Practice Address - Street 1:4601 PARK RD STE 400
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2284
Practice Address - Country:US
Practice Address - Phone:704-344-0491
Practice Address - Fax:704-344-0493
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6103353101YA0400X
NC5084101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103353Medicaid