Provider Demographics
NPI:1073983128
Name:DETIEGE, DAPHNE MILLER
Entity Type:Individual
Prefix:MRS
First Name:DAPHNE
Middle Name:MILLER
Last Name:DETIEGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5844
Mailing Address - Country:US
Mailing Address - Phone:318-325-8748
Mailing Address - Fax:318-325-8749
Practice Address - Street 1:908 N 3RD ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5844
Practice Address - Country:US
Practice Address - Phone:318-325-8748
Practice Address - Fax:318-325-8749
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAN543770OtherDEPARTMENT OF EDUCATION