Healthcare Provider Details

I. General information

NPI: 1912248790
Provider Name (Legal Business Name): MICHAEL JAMES DEWULF PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 CULBRETH DR
WILMINGTON NC
28405-3639
US

IV. Provider business mailing address

PO BOX 538622
ATLANTA GA
30353-8622
US

V. Phone/Fax

Practice location:
  • Phone: 910-742-9243
  • Fax: 888-746-1787
Mailing address:
  • Phone: 910-742-9243
  • Fax: 888-746-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPS008536L
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4848
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4848
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: