Basic Information
| Provider Information | |||||||||
| NPI: | 1346655891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEESE | ||||||||
| FirstName: | LISETTE | ||||||||
| MiddleName: | JENEE-MOORE | ||||||||
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| Credential: | LCSWA, LCAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4542 RAEFORD RD STE A11 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283040076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194189562 | ||||||||
| FaxNumber: | 8007993010 | ||||||||
| Practice Location | |||||||||
| Address1: | 10130 PERIMETER PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282162447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888497379 | ||||||||
| FaxNumber: | 8558577333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 3301 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | C010049 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.