Provider Demographics
NPI:1982245825
Name:CARSON, DEDE (MAADCII)
Entity Type:Individual
Prefix:
First Name:DEDE
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:MAADCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 BROOKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MO
Mailing Address - Zip Code:65605-8158
Mailing Address - Country:US
Mailing Address - Phone:417-569-2143
Mailing Address - Fax:
Practice Address - Street 1:1401 S ELLIOTT AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MO
Practice Address - Zip Code:65605-2103
Practice Address - Country:US
Practice Address - Phone:417-671-9856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO9512101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)