Basic Information
| Provider Information | |||||||||
| NPI: | 1255497186 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEKLE | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | CARLTON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 WOLF CREEK RD | ||||||||
| Address2: | |||||||||
| City: | WALNUT COVE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270525752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369944264 | ||||||||
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| Practice Location | |||||||||
| Address1: | 405 NC 65 | ||||||||
| Address2: | |||||||||
| City: | WENTWORTH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273750355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363428316 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 02/27/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | NC21393 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 892827B | 05 | NC | MEDICAID |