=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669700191
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUANITA DESHAZIOR LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2009
-----------------------------------------------------
Last Update Date | 11/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 L'ENFANT SQUARE, SE ALERNATIVE SOLUTIONS FOR YOUTH
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-584-1244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 HOLMES RUN PKWY
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22304-2834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-901-5592
-----------------------------------------------------
Fax | 571-257-5551
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 219194
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | PRC14035
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------