Basic Information
| Provider Information | |||||||||
| NPI: | 1811940349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESHAZO | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 BELLEVUE WAY NE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980045720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254555596 | ||||||||
| FaxNumber: | 4254513248 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 BELLEVUE WAY NE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980045720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254555596 | ||||||||
| FaxNumber: | 4254513248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 10/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | LD00002762 | WA | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 1092881 | 05 | WA | MEDICAID | 8450512 | 01 | WA | MEDICAID | OTHER |