Provider Demographics
NPI:1962191726
Name:DEATHERAGE, JULIA
Entity type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:DEATHERAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:
Other - Last Name:HEISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:32458 N RUSHMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60051-6666
Mailing Address - Country:US
Mailing Address - Phone:815-307-2501
Mailing Address - Fax:
Practice Address - Street 1:402 FEDERAL DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:779-220-6340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst