Provider Demographics
NPI:1760273429
Name:KASHOLA, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:KASHOLA
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 1:13175 MIDLAND TRL W
Mailing Address - Street 2:
Mailing Address - City:CRAWLEY
Mailing Address - State:WV
Mailing Address - Zip Code:24931-7010
Mailing Address - Country:US
Mailing Address - Phone:304-646-5664
Mailing Address - Fax:
Practice Address - Street 1:804 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:MAXWELTON
Practice Address - State:WV
Practice Address - Zip Code:24957-8066
Practice Address - Country:US
Practice Address - Phone:304-497-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374U00000XNursing Service Related ProvidersHome Health Aide