Basic Information
| Provider Information | |||||||||
| NPI: | 1699448704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIXON | ||||||||
| FirstName: | DEMETRICE | ||||||||
| MiddleName: | HUGHES | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1652 FOUNTAIN AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708106702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044016675 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11861 COURSEY BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708164404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256128656 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2021 | ||||||||
| LastUpdateDate: | 07/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 11371 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.