Healthcare Provider Details

I. General information

NPI: 1265140875
Provider Name (Legal Business Name): DEMA AGENCY CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 W RIALTO AVE UNIT B
SAN BERNARDINO CA
92410-3327
US

IV. Provider business mailing address

1074 PEACHTREE WALK NE UNIT B503
ATLANTA GA
30309-3968
US

V. Phone/Fax

Practice location:
  • Phone: 312-728-3509
  • Fax: 312-312-7364
Mailing address:
  • Phone: 630-880-2150
  • Fax: 312-312-7364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. CASSANDRA GOVAN
Title or Position: CEO
Credential:
Phone: 630-880-2150