Basic Information
| Provider Information | |||||||||
| NPI: | 1902123466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLING | ||||||||
| FirstName: | DESIREE | ||||||||
| MiddleName: | REBECCA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHILLIPS | ||||||||
| OtherFirstName: | DESIREE | ||||||||
| OtherMiddleName: | REBECCA | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | RR 1 BOX 205A2 | ||||||||
| Address2: | |||||||||
| City: | LOST CREEK | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263859722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043652327 | ||||||||
| FaxNumber: | 3045997800 | ||||||||
| Practice Location | |||||||||
| Address1: | 1052 MAPLE DR | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265052815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045992600 | ||||||||
| FaxNumber: | 3045997800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2010 | ||||||||
| LastUpdateDate: | 12/18/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/18/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | P/SLP-0467 | WV | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 4005078000 | 05 | WV | MEDICAID |