Provider Demographics
NPI:1578818761
Name:GAINES, DESHAY
Entity Type:Individual
Prefix:
First Name:DESHAY
Middle Name:
Last Name:GAINES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 S PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-3236
Mailing Address - Country:US
Mailing Address - Phone:209-810-5864
Mailing Address - Fax:
Practice Address - Street 1:503 S PERSHING AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-3236
Practice Address - Country:US
Practice Address - Phone:209-810-5864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)