| Deric J. Boston, Lcsw | |
|
1058 W Club Blvd Box 642 Durham NC 27701-1104 | |
| (919) 619-1032 | |
| Not Available |
| Full Name | Deric J. Boston, Lcsw |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 1058 W Club Blvd, Durham, North Carolina |
| Authorized Official Name and Position | Deric Boston (OWNER) |
| Authorized Official Contact | 9196191032 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Deric J. Boston, Lcsw 1058 W Club Blvd Ste 615 Durham NC 27701-1104 Ph: (919) 619-1032 | Deric J. Boston, Lcsw 1058 W Club Blvd Box 642 Durham NC 27701-1104 Ph: (919) 619-1032 |
| NPI Number | 1891959524 |
|---|---|
| Provider Enumeration Date | 07/11/2008 |
| Last Update Date | 05/21/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1891959524 | NPI | - | NPPES |
| 610643 | Medicaid | NC |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | C006078 (North Carolina) | Primary |
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