Provider Demographics
NPI:1174130686
Name:CARROLL, DEVAN JAMES (LCAS-A)
Entity type:Individual
Prefix:
First Name:DEVAN
Middle Name:JAMES
Last Name:CARROLL
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 JUDGES RD STE E
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-3651
Mailing Address - Country:US
Mailing Address - Phone:910-791-6767
Mailing Address - Fax:
Practice Address - Street 1:108 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-4586
Practice Address - Country:US
Practice Address - Phone:910-322-0845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)