Provider Demographics
NPI:1972830875
Name:POKE, DEMETRIC L (MA)
Entity Type:Individual
Prefix:MRS
First Name:DEMETRIC
Middle Name:L
Last Name:POKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7295 FOX TRACE CV
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-8734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7295 FOX TRACE CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-8734
Practice Address - Country:US
Practice Address - Phone:901-240-3653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH24Medicaid