Provider Demographics
NPI:1376943886
Name:DYKES, LEGREGORY JEROME SR (PSYCHOMETRIST)
Entity Type:Individual
Prefix:MR
First Name:LEGREGORY
Middle Name:JEROME
Last Name:DYKES
Suffix:SR
Gender:M
Credentials:PSYCHOMETRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-5231
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-5231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101YM0800X
GA246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy