Provider Demographics
NPI:1508546771
Name:DEATHERAGE, ZOE
Entity Type:Individual
Prefix:
First Name:ZOE
Middle Name:
Last Name:DEATHERAGE
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 1:6836 ISAACS ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6096
Mailing Address - Country:US
Mailing Address - Phone:479-927-4100
Mailing Address - Fax:479-927-1373
Practice Address - Street 1:6836 ISAACS ORCHARD RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-6096
Practice Address - Country:US
Practice Address - Phone:479-927-4100
Practice Address - Fax:479-927-1373
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR303859706Medicaid