Provider Demographics
NPI:1306407432
Name:ANDREA DESHA
Entity Type:Organization
Organization Name:ANDREA DESHA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:DESHA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:541-640-9888
Mailing Address - Street 1:25 NW PARK PL
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2954
Mailing Address - Country:US
Mailing Address - Phone:541-640-9888
Mailing Address - Fax:541-318-5600
Practice Address - Street 1:25 NW PARK PL
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2954
Practice Address - Country:US
Practice Address - Phone:541-640-9888
Practice Address - Fax:541-318-5600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-28
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500761072Medicaid