Provider Demographics
NPI:1811968712
Name:DEISSLER-GAGE, KATHLEEN ANN (BA)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANN
Last Name:DEISSLER-GAGE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:521 ELIZABETH PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-2821
Mailing Address - Country:US
Mailing Address - Phone:386-756-9534
Mailing Address - Fax:
Practice Address - Street 1:1220 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2810
Practice Address - Country:US
Practice Address - Phone:386-236-1703
Practice Address - Fax:386-236-3122
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health