Provider Demographics
NPI:1427785112
Name:STOVER, DEJA (LCSWA)
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:
Last Name:STOVER
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9404 GROVE SIDE LN APT 714
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-5485
Mailing Address - Country:US
Mailing Address - Phone:864-373-4621
Mailing Address - Fax:
Practice Address - Street 1:5820 E W T HARRIS BLVD STE 205
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-4032
Practice Address - Country:US
Practice Address - Phone:704-469-1243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0179951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty