Basic Information
| Provider Information | |||||||||
| NPI: | 1104481027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEESE | ||||||||
| FirstName: | PURLIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCAS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DIAL | ||||||||
| OtherFirstName: | PURLIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1023 FAIRFIELD CIR | ||||||||
| Address2: | |||||||||
| City: | RAEFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283766607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105503803 | ||||||||
| FaxNumber: | 9105503803 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 STAMPER RD STE G | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283034193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102237114 | ||||||||
| FaxNumber: | 9102237114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2019 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 25200 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.