Provider Demographics
NPI:1750008348
Name:DEVEAU, KONCHESSA (MT)
Entity type:Individual
Prefix:
First Name:KONCHESSA
Middle Name:
Last Name:DEVEAU
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 GLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3112
Mailing Address - Country:US
Mailing Address - Phone:757-298-6375
Mailing Address - Fax:
Practice Address - Street 1:11825 ROCKLANDING DRIVE
Practice Address - Street 2:YORK BLDG SUITE 2C
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606
Practice Address - Country:US
Practice Address - Phone:757-504-3114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019011654225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist