Provider Demographics
NPI:1669935318
Name:DESHAZOR, GABRIELLE (CPSS)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:DESHAZOR
Suffix:
Gender:F
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21501 GODDARD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4247
Mailing Address - Country:US
Mailing Address - Phone:734-250-7943
Mailing Address - Fax:734-785-8346
Practice Address - Street 1:21501 GODDARD RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4247
Practice Address - Country:US
Practice Address - Phone:734-250-7943
Practice Address - Fax:734-785-8346
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist