Provider Demographics
NPI:1285456814
Name:CARR, DWAINE
Entity type:Individual
Prefix:
First Name:DWAINE
Middle Name:
Last Name:CARR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4776 SHEFFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3157
Mailing Address - Country:US
Mailing Address - Phone:908-487-1017
Mailing Address - Fax:
Practice Address - Street 1:4776 SHEFFIELD CIR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3157
Practice Address - Country:US
Practice Address - Phone:908-487-1017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD317071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical