Provider Demographics
NPI:1568072577
Name:DOUGLAS, DESHONA
Entity Type:Individual
Prefix:
First Name:DESHONA
Middle Name:
Last Name:DOUGLAS
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 1:1850 PROVIDENCE LAKES BLVD APT 1301
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-1845
Mailing Address - Country:US
Mailing Address - Phone:216-358-7284
Mailing Address - Fax:
Practice Address - Street 1:1850 PROVIDENCE LAKES BLVD APT 1301
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-1845
Practice Address - Country:US
Practice Address - Phone:216-358-7284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator