Healthcare Provider Details

I. General information

NPI: 1497345078
Provider Name (Legal Business Name): GEORGE DESHAZOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N COURTHOUSE RD
NORTH CHESTERFIELD VA
23236-4045
US

IV. Provider business mailing address

707 N COURTHOUSE RD
NORTH CHESTERFIELD VA
23236-4045
US

V. Phone/Fax

Practice location:
  • Phone: 804-924-2236
  • Fax: 866-626-4469
Mailing address:
  • Phone: 804-924-2236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904000760
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: