Provider Demographics
NPI:1336474071
Name:TANTON, DEDRIA KAY (LBSW)
Entity Type:Individual
Prefix:MRS
First Name:DEDRIA
Middle Name:KAY
Last Name:TANTON
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:VOTAW
Mailing Address - State:TX
Mailing Address - Zip Code:77376-0126
Mailing Address - Country:US
Mailing Address - Phone:936-274-4649
Mailing Address - Fax:936-274-4649
Practice Address - Street 1:140 CR 2683 -- GUN STREET
Practice Address - Street 2:
Practice Address - City:RYE
Practice Address - State:TX
Practice Address - Zip Code:77369
Practice Address - Country:US
Practice Address - Phone:936-274-4649
Practice Address - Fax:936-274-4649
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41790171M00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management