Healthcare Provider Details

I. General information

NPI: 1578919684
Provider Name (Legal Business Name): DEMETRA K DANTZLER HCI, NHCE, M.S, B.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2016
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11499 WELLINGTON LN
HAMMOND LA
70403
US

IV. Provider business mailing address

11499 WELLINGTON LN
HAMMOND LA
70403-8607
US

V. Phone/Fax

Practice location:
  • Phone: 985-981-4274
  • Fax:
Mailing address:
  • Phone: 985-981-4274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: