Provider Demographics
NPI:1699392480
Name:DESIR, STEPHANIE KELLY
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KELLY
Last Name:DESIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2106
Mailing Address - Country:US
Mailing Address - Phone:304-382-8131
Mailing Address - Fax:
Practice Address - Street 1:1015 OAKHURST DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2049
Practice Address - Country:US
Practice Address - Phone:304-345-8101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-2104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist