Provider Demographics
NPI:1699131896
Name:FANT, DEITRA LATRICE (MA,NCC,LCPC,LPC)
Entity type:Individual
Prefix:MRS
First Name:DEITRA
Middle Name:LATRICE
Last Name:FANT
Suffix:
Gender:F
Credentials:MA,NCC,LCPC,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 NATIONAL PLZ STE 300
Mailing Address - Street 2:
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-1153
Mailing Address - Country:US
Mailing Address - Phone:703-857-5354
Mailing Address - Fax:
Practice Address - Street 1:118 N SAINT ASAPH ST STE G
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-3110
Practice Address - Country:US
Practice Address - Phone:703-857-5354
Practice Address - Fax:571-601-4607
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X, 172V00000X, 251S00000X, 261QM0801X, 261QM0850X, 261QM0855X
MDLC10267101YM0800X, 101YP2500X
LA08861101YP2500X
VA0701009874101YP2500X
DCPRC15297101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD566703141985Medicaid
DC566703141985Medicaid
MD20731Medicaid