Provider Demographics
NPI:1235621889
Name:CONNETT, DEVA M
Entity Type:Individual
Prefix:MS
First Name:DEVA
Middle Name:M
Last Name:CONNETT
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 1:1300 S FIGUEROA ST APT 114
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-2802
Mailing Address - Country:US
Mailing Address - Phone:140-277-0416
Mailing Address - Fax:
Practice Address - Street 1:3205 OCEAN PARK BLVD STE 240
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-3234
Practice Address - Country:US
Practice Address - Phone:323-364-8489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABC-DMT-1164225600000X
CALPCC-4657101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist