Provider Demographics
NPI:1184173486
Name:WHITE, DEIDRE DEACON (PT, DPT)
Entity type:Individual
Prefix:
First Name:DEIDRE
Middle Name:DEACON
Last Name:WHITE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:DEIDRE
Other - Middle Name:
Other - Last Name:DEACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1285 FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-3505
Mailing Address - Country:US
Mailing Address - Phone:540-294-3625
Mailing Address - Fax:
Practice Address - Street 1:1285 FLORIDA ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-3505
Practice Address - Country:US
Practice Address - Phone:540-294-3625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT293126225100000X
VA2305210672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist