=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912384017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIQUE'S PROFESSIONAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2015
-----------------------------------------------------
Last Update Date | 04/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1799 STUMPF BLVD BUILDING 7, SUITE 9A
-----------------------------------------------------
City | TERRYTOWN
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70056-3950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-864-7834
-----------------------------------------------------
Fax | 844-864-7834
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5501 TULLIS DR APT 2-103
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70131-8907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-864-7834
-----------------------------------------------------
Fax | 844-864-7834
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWENER/MANAGER
-----------------------------------------------------
Name | MR. VONNCEDRIC LEE DIXON SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 844-864-7834
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 14432993
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------