Provider Demographics
NPI:1780229542
Name:HUTSON, DESEREE NICOLE
Entity type:Individual
Prefix:
First Name:DESEREE
Middle Name:NICOLE
Last Name:HUTSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:DESEREE
Other - Middle Name:NICOLE
Other - Last Name:MAIETTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:209 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:POCOMOKE CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21851-1423
Mailing Address - Country:US
Mailing Address - Phone:240-329-1936
Mailing Address - Fax:
Practice Address - Street 1:10514 RACETRACK RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3241
Practice Address - Country:US
Practice Address - Phone:410-973-2301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2025-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA1423103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD483106300Medicaid