Provider Demographics
NPI:1316371313
Name:EYSAMAN, DEAVON ELIZABETH (SLP)
Entity Type:Individual
Prefix:MISS
First Name:DEAVON
Middle Name:ELIZABETH
Last Name:EYSAMAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 TULIP DR
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-5207
Mailing Address - Country:US
Mailing Address - Phone:315-542-1449
Mailing Address - Fax:
Practice Address - Street 1:405 TULIP DR
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-5207
Practice Address - Country:US
Practice Address - Phone:315-542-1449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024114-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist