Provider Demographics
NPI:1124656467
Name:DRIVER, DESIREE (SC)
Entity type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:
Last Name:DRIVER
Suffix:
Gender:F
Credentials:SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 WELSH RD STE 209
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-2211
Mailing Address - Country:US
Mailing Address - Phone:215-214-5104
Mailing Address - Fax:800-218-2559
Practice Address - Street 1:2417 WELSH RD STE 209
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2211
Practice Address - Country:US
Practice Address - Phone:215-214-5104
Practice Address - Fax:800-218-2559
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103496547-0001Medicaid