Provider Demographics
NPI:1477628048
Name:DESHAZER, CHANTELLE YVETTE (LAC)
Entity Type:Individual
Prefix:MS
First Name:CHANTELLE
Middle Name:YVETTE
Last Name:DESHAZER
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 1:2356 MOORE ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3017
Mailing Address - Country:US
Mailing Address - Phone:619-325-0771
Mailing Address - Fax:619-325-0395
Practice Address - Street 1:2356 MOORE ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3017
Practice Address - Country:US
Practice Address - Phone:619-325-0771
Practice Address - Fax:619-325-0395
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 5256171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist