Provider Demographics
NPI:1922415074
Name:DEVEREUX
Entity Type:Organization
Organization Name:DEVEREUX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARISOL
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDSAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-738-5543
Mailing Address - Street 1:120 E NEW YORK AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-5568
Mailing Address - Country:US
Mailing Address - Phone:386-738-5543
Mailing Address - Fax:866-596-2824
Practice Address - Street 1:120 E NEW YORK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-5568
Practice Address - Country:US
Practice Address - Phone:386-738-5543
Practice Address - Fax:866-596-2824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health