Provider Demographics
NPI:1811940349
Name:DESHAZO, VICKI A
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:A
Last Name:DESHAZO
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 1:208 BELLEVUE WAY NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-5720
Mailing Address - Country:US
Mailing Address - Phone:425-455-5596
Mailing Address - Fax:425-451-3248
Practice Address - Street 1:208 BELLEVUE WAY NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5720
Practice Address - Country:US
Practice Address - Phone:425-455-5596
Practice Address - Fax:425-451-3248
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALD00002762231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1092881Medicaid
WA8450512OtherMEDICAID
WA1092881Medicaid