Provider Demographics
NPI:1275307795
Name:KIESTER, DEANNA (LAC)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:KIESTER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5245 N MAIN DR
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-8708
Mailing Address - Country:US
Mailing Address - Phone:602-881-2406
Mailing Address - Fax:
Practice Address - Street 1:5245 N MAIN DR
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-8708
Practice Address - Country:US
Practice Address - Phone:602-881-2406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-17429101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health