Healthcare Provider Details

I. General information

NPI: 1043553894
Provider Name (Legal Business Name): MARKITA DISMUKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2013
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 N 18TH ST STE 210
MONROE LA
71201-5462
US

IV. Provider business mailing address

920 TAMPA ST
TALLULAH LA
71282-5040
US

V. Phone/Fax

Practice location:
  • Phone: 318-503-8553
  • Fax:
Mailing address:
  • Phone: 318-341-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: