Provider Demographics
NPI:1902123466
Name:POLING, DESIREE REBECCA (SLP)
Entity Type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:REBECCA
Last Name:POLING
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MISS
Other - First Name:DESIREE
Other - Middle Name:REBECCA
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:RR 1 BOX 205A2
Mailing Address - Street 2:
Mailing Address - City:LOST CREEK
Mailing Address - State:WV
Mailing Address - Zip Code:26385-9722
Mailing Address - Country:US
Mailing Address - Phone:304-365-2327
Mailing Address - Fax:304-599-7800
Practice Address - Street 1:1052 MAPLE DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2815
Practice Address - Country:US
Practice Address - Phone:304-599-2600
Practice Address - Fax:304-599-7800
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVP/SLP-0467235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4005078000Medicaid
WV4005078000Medicaid