Provider Demographics
NPI:1750848222
Name:DESHON, KATELYN MARIE
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:DESHON
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 1:1645 DUNLAWTON AVE APT 1124
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8959
Mailing Address - Country:US
Mailing Address - Phone:330-224-8348
Mailing Address - Fax:
Practice Address - Street 1:1128 BEVILLE RD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5747
Practice Address - Country:US
Practice Address - Phone:386-267-3161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician