Provider Demographics
NPI:1912406760
Name:DESANDO, DENISE MCCLUNG
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:MCCLUNG
Last Name:DESANDO
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 1:613 CAMDEN DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405-2032
Mailing Address - Country:US
Mailing Address - Phone:540-373-2798
Mailing Address - Fax:
Practice Address - Street 1:20 PENDLETON RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22405-3041
Practice Address - Country:US
Practice Address - Phone:540-373-7366
Practice Address - Fax:540-371-3788
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA22022007625235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2202007625OtherBOARD OF AUDIOLOGY AND SPEECH-LANGUAGE PATHOLOGY