Provider Demographics
NPI:1356713606
Name:DENNIS, DEADRA
Entity type:Individual
Prefix:
First Name:DEADRA
Middle Name:
Last Name:DENNIS
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 1:2816 CALICO ROCK CV
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-8014
Mailing Address - Country:US
Mailing Address - Phone:901-483-3741
Mailing Address - Fax:
Practice Address - Street 1:2816 CALICO ROCK CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672
Practice Address - Country:US
Practice Address - Phone:901-483-3741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst