Provider Demographics
NPI:1831133156
Name:DESHA, DOROTHY (LCSW, MSW)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:DESHA
Suffix:
Gender:F
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:FRANKLINVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14737-0213
Mailing Address - Country:US
Mailing Address - Phone:716-676-3031
Mailing Address - Fax:716-676-2475
Practice Address - Street 1:2 PARK SQ
Practice Address - Street 2:
Practice Address - City:FRANKLINVILLE
Practice Address - State:NY
Practice Address - Zip Code:14737-1110
Practice Address - Country:US
Practice Address - Phone:716-676-3031
Practice Address - Fax:716-676-2475
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPRO39593-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01585946Medicaid
NYCC1347Medicare ID - Type Unspecified