Provider Demographics
NPI:1649545898
Name:CARTER, DESHAE GUSELLA
Entity type:Individual
Prefix:
First Name:DESHAE
Middle Name:GUSELLA
Last Name:CARTER
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 1:3509 LAKE AVE
Mailing Address - Street 2:APT 1151
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-5606
Mailing Address - Country:US
Mailing Address - Phone:803-450-9018
Mailing Address - Fax:803-497-3757
Practice Address - Street 1:2708 NE 14TH STREET, SUITE 5
Practice Address - Street 2:
Practice Address - City:POMPANO
Practice Address - State:FL
Practice Address - Zip Code:33062
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC100346182222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist