Provider Demographics
NPI:1487842159
Name:DESPAIN, SALLY A (RC)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:DESPAIN
Suffix:
Gender:F
Credentials:RC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 E HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-2629
Mailing Address - Country:US
Mailing Address - Phone:509-684-4597
Mailing Address - Fax:
Practice Address - Street 1:309 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-3247
Practice Address - Country:US
Practice Address - Phone:509-684-3870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00042138101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health