Provider Demographics
NPI:1306195185
Name:DEVEREUX
Entity Type:Organization
Organization Name:DEVEREUX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:DENICE
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:954-560-2748
Mailing Address - Street 1:6365 TAFT ST. SUITE 2002
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024
Mailing Address - Country:US
Mailing Address - Phone:954-962-1225
Mailing Address - Fax:
Practice Address - Street 1:6365 TAFT ST. SUITE 2002
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024
Practice Address - Country:US
Practice Address - Phone:954-962-1225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicaid