Provider Demographics
NPI:1154811222
Name:AUGUSTINE, DEIRDRE ROSE
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:ROSE
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8420 UNIVERSITY EXEC PARK DR STE 810
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1346
Mailing Address - Country:US
Mailing Address - Phone:704-770-5837
Mailing Address - Fax:
Practice Address - Street 1:8420 UNIVERSITY EXEC PARK DR STE 810
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1346
Practice Address - Country:US
Practice Address - Phone:704-894-9678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician