Provider Demographics
NPI:1518396522
Name:PROPHET, DELEDA DALE
Entity Type:Individual
Prefix:DR
First Name:DELEDA
Middle Name:DALE
Last Name:PROPHET
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:DELEDA
Other - Middle Name:DALE
Other - Last Name:PROPHET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:198 S MACARTHUR DR
Mailing Address - Street 2:198 S. MACARTHUR DRIVE
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-6370
Mailing Address - Country:US
Mailing Address - Phone:229-336-2247
Mailing Address - Fax:229-336-8009
Practice Address - Street 1:198 S MACARTHUR DR
Practice Address - Street 2:198 S. MACARTHUR DRIVE
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-6370
Practice Address - Country:US
Practice Address - Phone:229-336-2247
Practice Address - Fax:229-336-8009
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-11
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FM101YM0800X
GA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health