Provider Demographics
NPI:1881241479
Name:BRESCOACH, KILEY RHAE
Entity type:Individual
Prefix:
First Name:KILEY
Middle Name:RHAE
Last Name:BRESCOACH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:KILEY
Other - Middle Name:RHAE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 995
Mailing Address - Street 2:
Mailing Address - City:BARRACKVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26559-0995
Mailing Address - Country:US
Mailing Address - Phone:304-207-0087
Mailing Address - Fax:
Practice Address - Street 1:704 ICE ST
Practice Address - Street 2:
Practice Address - City:BARRACKVILLE
Practice Address - State:WV
Practice Address - Zip Code:26559
Practice Address - Country:US
Practice Address - Phone:304-207-0087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV104100000X
WVDP009455491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker