Provider Demographics
NPI:1780391771
Name:WARD, DERICK CARLTON (LCAS-A)
Entity type:Individual
Prefix:
First Name:DERICK
Middle Name:CARLTON
Last Name:WARD
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 S WESTGATE DR STE D
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-1632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:319 S WESTGATE DR STE D
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-1632
Practice Address - Country:US
Practice Address - Phone:866-700-1606
Practice Address - Fax:866-338-5921
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-24422101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)