Healthcare Provider Details

I. General information

NPI: 1669700191
Provider Name (Legal Business Name): JUANITA DESHAZIOR LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 L'ENFANT SQUARE, SE ALERNATIVE SOLUTIONS FOR YOUTH
WASHINGTON DC
20020
US

IV. Provider business mailing address

5300 HOLMES RUN PKWY
ALEXANDRIA VA
22304-2834
US

V. Phone/Fax

Practice location:
  • Phone: 202-584-1244
  • Fax:
Mailing address:
  • Phone: 703-901-5592
  • Fax: 571-257-5551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number219194
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPRC14035
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: