Healthcare Provider Details

I. General information

NPI: 1275004111
Provider Name (Legal Business Name): ELIZABETH DEROUIN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10926 DAVID TAYLOR DR SUITE 120 PMB1390
CHARLOTTE NC
28262-0039
US

IV. Provider business mailing address

10926 DAVID TAYLOR DRIVE SUITE 120 PMB1390
NEWTON NC
28658-3819
US

V. Phone/Fax

Practice location:
  • Phone: 910-494-6000
  • Fax:
Mailing address:
  • Phone: 910-494-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5417
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810007114
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: