Provider Demographics
NPI:1811667173
Name:DEVERO, LANCE CORY
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:CORY
Last Name:DEVERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8406 S 49TH LN
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2159
Mailing Address - Country:US
Mailing Address - Phone:215-678-7702
Mailing Address - Fax:
Practice Address - Street 1:8406 S 49TH LN
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2159
Practice Address - Country:US
Practice Address - Phone:215-678-7702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children