Provider Demographics
NPI:1295785988
Name:IRVINE, JOAN DOREEN (MS, LPA)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:DOREEN
Last Name:IRVINE
Suffix:
Gender:F
Credentials:MS, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6711 LINDA LAKE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-4008
Mailing Address - Country:US
Mailing Address - Phone:252-658-5522
Mailing Address - Fax:
Practice Address - Street 1:3205 FREEDOM DR STE 7500
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-3490
Practice Address - Country:US
Practice Address - Phone:704-517-4632
Practice Address - Fax:252-633-1548
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2149103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107164Medicaid
NC487799200OtherEPA WORK COMP
NCD4850OtherMEDCOST
NC046CCOtherBLUE CROSS BLUE SHIELD