Healthcare Provider Details

I. General information

NPI: 1134832397
Provider Name (Legal Business Name): DEJA MONIQUE MINOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3541 RANDOLPH RD STE 206
CHARLOTTE NC
28211-1253
US

IV. Provider business mailing address

1435 E NC HIGHWAY 54 APT L
DURHAM NC
27713-2666
US

V. Phone/Fax

Practice location:
  • Phone: 704-381-8336
  • Fax:
Mailing address:
  • Phone: 336-624-5309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP018308
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: