Provider Demographics
NPI:1043749138
Name:DEBETAZ, DOMINIQUE NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:NICOLE
Last Name:DEBETAZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:DEBETAZ
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:24848 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-6701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10431 SIEGEN LN STE 103
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-4984
Practice Address - Country:US
Practice Address - Phone:225-777-6824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA144111041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1255681128Medicaid