Provider Demographics
NPI:1780181040
Name:FLANAGAN, DEAUNTAE
Entity Type:Individual
Prefix:MR
First Name:DEAUNTAE
Middle Name:
Last Name:FLANAGAN
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 1:4165 OLD DOWLEN RD
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-6608
Mailing Address - Country:US
Mailing Address - Phone:757-806-8218
Mailing Address - Fax:
Practice Address - Street 1:4165 OLD DOWLEN RD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-6608
Practice Address - Country:US
Practice Address - Phone:757-806-8218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$Medicaid
GA$$$$$$$$$Medicaid