Healthcare Provider Details

I. General information

NPI: 1639993462
Provider Name (Legal Business Name): DESHANNA PROSPER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2024
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GRAND CONCOURSE
BRONX NY
10457-7679
US

IV. Provider business mailing address

1650 GRAND CONCOURSE
BRONX NY
10457-7679
US

V. Phone/Fax

Practice location:
  • Phone: 718-992-7669
  • Fax:
Mailing address:
  • Phone: 646-404-6862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number097981
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: