Provider Demographics
NPI:1063188787
Name:DEATHERAGE, NORI
Entity type:Individual
Prefix:
First Name:NORI
Middle Name:
Last Name:DEATHERAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 E COAST HWY STE 210
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2131
Mailing Address - Country:US
Mailing Address - Phone:949-231-9555
Mailing Address - Fax:
Practice Address - Street 1:2721 E COAST HWY STE 210
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2131
Practice Address - Country:US
Practice Address - Phone:949-231-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-22
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9981101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALPCC9981OtherLPCC