Provider Demographics
NPI:1518704501
Name:DAME, DEIDRA (LSW)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:DAME
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 DEVONSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7295
Mailing Address - Country:US
Mailing Address - Phone:217-904-3035
Mailing Address - Fax:
Practice Address - Street 1:495 DEVONSHIRE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7295
Practice Address - Country:US
Practice Address - Phone:217-904-3035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150113585101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional