Provider Demographics
NPI:1891223491
Name:DEAVENS, VICTORIAL RENETT
Entity Type:Individual
Prefix:
First Name:VICTORIAL
Middle Name:RENETT
Last Name:DEAVENS
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 1:2525 YOUREE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3600
Mailing Address - Country:US
Mailing Address - Phone:662-241-7097
Mailing Address - Fax:662-245-0511
Practice Address - Street 1:428 24TH AVE N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-1945
Practice Address - Country:US
Practice Address - Phone:662-241-7097
Practice Address - Fax:662-245-0155
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor