Provider Demographics
NPI:1144637240
Name:DESKALO, AVITAL YAEL (LP)
Entity type:Individual
Prefix:
First Name:AVITAL
Middle Name:YAEL
Last Name:DESKALO
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6421 N ELM TREE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4127
Mailing Address - Country:US
Mailing Address - Phone:414-324-8283
Mailing Address - Fax:
Practice Address - Street 1:277 S. WASHINGTON ST, SUITE 201, #1025
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314
Practice Address - Country:US
Practice Address - Phone:703-249-9084
Practice Address - Fax:202-650-6362
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD713690103T00000X
DCPSY1001213103T00000X
NE4638101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47037660631Medicaid
NE10026139700Medicaid
NE47037660624Medicaid