Provider Demographics
NPI:1093167751
Name:SPIVEY, DEZMOND I
Entity Type:Individual
Prefix:
First Name:DEZMOND
Middle Name:I
Last Name:SPIVEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 FERRAND ST
Mailing Address - Street 2:STE. 23
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-3234
Mailing Address - Country:US
Mailing Address - Phone:318-323-0463
Mailing Address - Fax:318-323-0465
Practice Address - Street 1:2404 FERRAND ST
Practice Address - Street 2:STE. 23
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3234
Practice Address - Country:US
Practice Address - Phone:318-323-0463
Practice Address - Fax:318-323-0465
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health