Provider Demographics
NPI:1629510680
Name:DORSEY, CEDRICK
Entity Type:Individual
Prefix:
First Name:CEDRICK
Middle Name:
Last Name:DORSEY
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 1:109 BERNICE DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7621
Mailing Address - Country:US
Mailing Address - Phone:318-516-6454
Mailing Address - Fax:
Practice Address - Street 1:645 HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203
Practice Address - Country:US
Practice Address - Phone:318-343-6966
Practice Address - Fax:318-345-7123
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA103TB0200X
101YM0800X, 106E00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst