Provider Demographics
NPI:1457607608
Name:DESHAZO, KATHLEEN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:DESHAZO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:DESHAZO-JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:5941 TUSKWILLOW DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-8154
Mailing Address - Country:US
Mailing Address - Phone:804-901-0681
Mailing Address - Fax:
Practice Address - Street 1:5941 TUSKWILLOW DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-8154
Practice Address - Country:US
Practice Address - Phone:804-901-0681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040078751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical