Provider Demographics
NPI:1215428628
Name:MARTIN, DEMEISHA LASHA
Entity type:Individual
Prefix:
First Name:DEMEISHA
Middle Name:LASHA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3683 CANE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ADDIS
Mailing Address - State:LA
Mailing Address - Zip Code:70710-2223
Mailing Address - Country:US
Mailing Address - Phone:225-206-1826
Mailing Address - Fax:
Practice Address - Street 1:3683 CANE RIDGE DR
Practice Address - Street 2:
Practice Address - City:ADDIS
Practice Address - State:LA
Practice Address - Zip Code:70710-2223
Practice Address - Country:US
Practice Address - Phone:225-206-1826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X, 101Y00000X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2403162724901Medicaid