Provider Demographics
NPI:1497762660
Name:DEATHERAGE, BILL RAY (PSYD, MFTI)
Entity Type:Individual
Prefix:
First Name:BILL
Middle Name:RAY
Last Name:DEATHERAGE
Suffix:
Gender:M
Credentials:PSYD, MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23446 VIA JACINTO
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1162
Mailing Address - Country:US
Mailing Address - Phone:949-586-4634
Mailing Address - Fax:
Practice Address - Street 1:405 W 5TH ST
Practice Address - Street 2:SUITE 590
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4519
Practice Address - Country:US
Practice Address - Phone:714-834-5015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAS0993236101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health