Provider Demographics
NPI:1588304695
Name:DESOTA, ATHENEA ANN NMI
Entity type:Individual
Prefix:
First Name:ATHENEA ANN
Middle Name:NMI
Last Name:DESOTA
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 1:825 JADWIN AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3589
Mailing Address - Country:US
Mailing Address - Phone:509-946-1020
Mailing Address - Fax:509-946-0827
Practice Address - Street 1:825 JADWIN AVE STE 250
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3589
Practice Address - Country:US
Practice Address - Phone:509-946-1020
Practice Address - Fax:509-946-0827
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YA0400X
WASUDP00006313101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)