Provider Demographics
NPI:1023215266
Name:DEATHERAGE, WILLIAM JEFFERY I (CDP)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:JEFFERY
Last Name:DEATHERAGE
Suffix:I
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 SAGEWOOD ST
Mailing Address - Street 2:NA
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9679
Mailing Address - Country:US
Mailing Address - Phone:509-851-8507
Mailing Address - Fax:
Practice Address - Street 1:6725 W CLEARWATER AVE
Practice Address - Street 2:STE B
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-1724
Practice Address - Country:US
Practice Address - Phone:509-735-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00003184171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator