Provider Demographics
NPI:1275501439
Name:DESMOND, ALAN LOUIS (AUD CCC-A)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:LOUIS
Last Name:DESMOND
Suffix:
Gender:M
Credentials:AUD CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 NEW HOPE ROAD
Mailing Address - Street 2:SUITE #19
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2272
Mailing Address - Country:US
Mailing Address - Phone:304-487-2487
Mailing Address - Fax:304-431-3367
Practice Address - Street 1:508 NEW HOPE ROAD
Practice Address - Street 2:SUITE #19
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2272
Practice Address - Country:US
Practice Address - Phone:304-487-2487
Practice Address - Fax:304-431-3367
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA0074231H00000X
VA2201000219231H00000X
WV447231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9460000000Medicaid
DE0534283OtherPALMETTO GBA MEDICARE PTAN NUMBER BLFD OFFICE
VA9450513Medicaid
DE0534282OtherPALMETTO GBA MEDICARE PTAN NUMBER PCTN OFFICE
640000237OtherRR MEDICARE PALMETTO GBA
WV9460000000Medicaid