MEDICARE: DEVIN MARTIE XAYASOMLOTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCSW112035	CA
2	1041C0700X	Clinical Social Worker	C013435	NC

General Provider Information

NPI Number	:	1134603814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVIN MARTIE XAYASOMLOTH

Provider Business Mailing Address
First Line	:	1810 BACK CREEK DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-2159
Country	:	US
Telephone Number	:	448-263-0050
Fax Number	:

Provider Business Practice Location Address
First Line	:	1810 BACK CREEK DRIVE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213
Country	:	US
Telephone Number	:	844-263-0050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2018
Last Update Date	:	04/08/2024

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Directions to “ DEVIN MARTIE XAYASOMLOTH ” Practice Location

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