Provider Demographics
NPI:1306992193
Name:DETWEILER, ELIZABETH (LCAS, LCSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:DETWEILER
Suffix:
Gender:F
Credentials:LCAS, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1171
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27588-1171
Mailing Address - Country:US
Mailing Address - Phone:919-622-5776
Mailing Address - Fax:
Practice Address - Street 1:839 WAKE FOREST BUSINESS PARK STE C
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-7335
Practice Address - Country:US
Practice Address - Phone:919-622-5776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2010-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0069181041C0700X
NC1413101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112148Medicaid