Healthcare Provider Details

I. General information

NPI: 1851078471
Provider Name (Legal Business Name): VERQUEZ DEMARQUE AUSTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 3RD AVE
GASTONIA NC
28052-4317
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 704-874-3300
  • Fax: 704-874-0065
Mailing address:
  • Phone: 704-874-1904
  • Fax: 704-865-4614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP019239
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: