Provider Demographics
NPI:1487076733
Name:BATTLE, DEMETRIUS
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:BATTLE
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 1:840 GATESHEAD LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6668
Mailing Address - Country:US
Mailing Address - Phone:770-558-9596
Mailing Address - Fax:
Practice Address - Street 1:840 GATESHEAD LN
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-6668
Practice Address - Country:US
Practice Address - Phone:770-558-9596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45-4567251253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency