Healthcare Provider Details

I. General information

NPI: 1659585099
Provider Name (Legal Business Name): ALLISON MARIE DEATHERAGE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W HILL BLVD
CHARLESTON AFB SC
29404-4704
US

IV. Provider business mailing address

PO BOX 21467
COLUMBUS OH
43221-0467
US

V. Phone/Fax

Practice location:
  • Phone: 843-963-6852
  • Fax:
Mailing address:
  • Phone: 614-380-9371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7351
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: