MEDICARE: MRS. CASEY MICHELLE DEACON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1975-C	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5Y807	OTHER	AR	AR BLUE CROSS #

General Provider Information

NPI Number	:	1871695742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CASEY MICHELLE DEACON LCSW

Provider Business Mailing Address
First Line	:	1231 EAST SOUTHERN HEIGHTS
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72701
Country	:	US
Telephone Number	:	479-387-4535
Fax Number	:

Provider Business Practice Location Address
First Line	:	1231 EAST SOUTHERN HEIGHTS
Second Line	:
City	:	FAYETTEVILLE
State	:	AR
Zip	:	72701
Country	:	US
Telephone Number	:	479-387-4535
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	07/21/2022

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