Provider Demographics
NPI:1114647013
Name:DEAN, CEDRIC (CPP)
Entity type:Individual
Prefix:
First Name:CEDRIC
Middle Name:
Last Name:DEAN
Suffix:
Gender:M
Credentials:CPP
Other - Prefix:MR
Other - First Name:CEDRIC
Other - Middle Name:
Other - Last Name:DEAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPP
Mailing Address - Street 1:5502 MCCHESNEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-7188
Mailing Address - Country:US
Mailing Address - Phone:704-492-5509
Mailing Address - Fax:
Practice Address - Street 1:2001 CATHERINE SIMMONS AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-4677
Practice Address - Country:US
Practice Address - Phone:704-492-1533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021877201171WH0202X, 251K00000X, 305R00000X, 405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No171WH0202XOther Service ProvidersContractorHome Modifications
No251K00000XAgenciesPublic Health or Welfare
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1497473086OtherPRIVATE INSURANCE
NC832424267Medicaid
NC000005049292OtherDMV