Provider Demographics
NPI:1861993602
Name:DEWEESE, DAXEA (LSW, CDAC-I)
Entity type:Individual
Prefix:
First Name:DAXEA
Middle Name:
Last Name:DEWEESE
Suffix:
Gender:F
Credentials:LSW, CDAC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 CAPURRO WAY STE 105
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-8586
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2105 CAPURRO WAY STE 105
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-8586
Practice Address - Country:US
Practice Address - Phone:775-455-4260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV02292-I101YA0400X
NV7635-S104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)