Provider Demographics
NPI:1235707456
Name:DESHIELDS, AYDELOTTE A
Entity type:Individual
Prefix:
First Name:AYDELOTTE
Middle Name:A
Last Name:DESHIELDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8115 MAPLE LAWN BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2683
Mailing Address - Country:US
Mailing Address - Phone:718-360-9548
Mailing Address - Fax:718-874-0052
Practice Address - Street 1:8115 MAPLE LAWN BLVD STE 350
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2683
Practice Address - Country:US
Practice Address - Phone:718-360-9548
Practice Address - Fax:718-874-0052
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician