Provider Demographics
NPI:1477670297
Name:CLAXTON, DIEDREA STEVERSON (PHD)
Entity type:Individual
Prefix:
First Name:DIEDREA
Middle Name:STEVERSON
Last Name:CLAXTON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CONFEDERATE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-2252
Mailing Address - Country:US
Mailing Address - Phone:706-342-3130
Mailing Address - Fax:
Practice Address - Street 1:1200 CONFEDERATE RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-2252
Practice Address - Country:US
Practice Address - Phone:706-342-3130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1935103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist