Provider Demographics
NPI:1710567375
Name:DEZINE, MANOUCHEKA S
Entity Type:Individual
Prefix:
First Name:MANOUCHEKA
Middle Name:S
Last Name:DEZINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 NW 30TH WAY
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33311-8497
Mailing Address - Country:US
Mailing Address - Phone:305-735-1340
Mailing Address - Fax:
Practice Address - Street 1:111 NW 183RD ST STE 404
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-4619
Practice Address - Country:US
Practice Address - Phone:305-735-1340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW8528104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker