Provider Demographics
NPI:1376060343
Name:BURNELL, DESHAWN
Entity Type:Individual
Prefix:
First Name:DESHAWN
Middle Name:
Last Name:BURNELL
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 1:4024 MONTCALM PL
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-6643
Mailing Address - Country:US
Mailing Address - Phone:916-462-0181
Mailing Address - Fax:
Practice Address - Street 1:2345 FAIR OAKS BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4708
Practice Address - Country:US
Practice Address - Phone:916-480-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT10459225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist