1962916254 NPI number — DR. CHAITRA ELISE DEVEREAUX PSYD

Table of content: DR. CHAITRA ELISE DEVEREAUX PSYD (NPI 1962916254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962916254 NPI number — DR. CHAITRA ELISE DEVEREAUX PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEVEREAUX
Provider First Name:
CHAITRA
Provider Middle Name:
ELISE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962916254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12904 126TH CT NE APT J104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KIRKLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98034-3274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-287-7753
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22530 SE 64TH PL STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ISSAQUAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98027-5353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-677-8686
Provider Business Practice Location Address Fax Number:
425-961-0783
Provider Enumeration Date:
11/22/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X , with the licence number:  MC60535134 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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