Provider Demographics
NPI:1700641545
Name:ADDISON, DEDRAIN
Entity Type:Individual
Prefix:
First Name:DEDRAIN
Middle Name:
Last Name:ADDISON
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 1:9898 ROCKFISH RD
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-6727
Mailing Address - Country:US
Mailing Address - Phone:910-580-8434
Mailing Address - Fax:
Practice Address - Street 1:4701 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2697
Practice Address - Country:US
Practice Address - Phone:910-738-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0201721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty