Provider Demographics
NPI:1457697880
Name:DEMOSS, STACIA DAWN (AUD)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:DAWN
Last Name:DEMOSS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:STACAI
Other - Middle Name:DAWN
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1425 EARL L CORE RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-5885
Mailing Address - Country:US
Mailing Address - Phone:304-413-0184
Mailing Address - Fax:304-413-0185
Practice Address - Street 1:1425 EARL L CORE RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-5885
Practice Address - Country:US
Practice Address - Phone:304-413-0184
Practice Address - Fax:304-413-0185
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA-0288231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12140181OtherASHA CERTIFICATE OF CLINICAL COMPETENCE
WVA-0288OtherSTATE OF WV LICENSE