Basic Information
| Provider Information | |||||||||
| NPI: | 1780391771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | DERICK | ||||||||
| MiddleName: | CARLTON | ||||||||
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| Credential: | LCAS-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 319 S WESTGATE DR STE D | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274071632 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 319 S WESTGATE DR STE D | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274071632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667001606 | ||||||||
| FaxNumber: | 8663385921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2022 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS-24422 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.