Provider Demographics
NPI:1063979474
Name:DESHA, NEAL EVAN (MED, LPC)
Entity type:Individual
Prefix:
First Name:NEAL
Middle Name:EVAN
Last Name:DESHA
Suffix:
Gender:M
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 S RAFORD DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-2336
Mailing Address - Country:US
Mailing Address - Phone:573-821-3513
Mailing Address - Fax:
Practice Address - Street 1:440 S MARKET AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-2026
Practice Address - Country:US
Practice Address - Phone:573-821-3513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004014921101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO14407460OtherCAQH