Provider Demographics
NPI:1164031811
Name:MEADERS, DESHANAE MICHELLE
Entity Type:Individual
Prefix:
First Name:DESHANAE
Middle Name:MICHELLE
Last Name:MEADERS
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 1:2742 LORRING DR APT 204
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-3434
Mailing Address - Country:US
Mailing Address - Phone:980-318-0542
Mailing Address - Fax:
Practice Address - Street 1:2742 LORRING DR APT 204
Practice Address - Street 2:
Practice Address - City:DISTRICT HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20747-3434
Practice Address - Country:US
Practice Address - Phone:980-318-0542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0000392893012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer