Provider Demographics
NPI:1003096199
Name:DESHAZO, REBECCA LYNNE (MA CCC SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNNE
Last Name:DESHAZO
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3419 MELROSE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-1608
Mailing Address - Country:US
Mailing Address - Phone:910-257-2005
Mailing Address - Fax:
Practice Address - Street 1:3637 SYCAMORE DAIRY RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-3415
Practice Address - Country:US
Practice Address - Phone:910-487-1832
Practice Address - Fax:910-487-6950
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4623235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist