Provider Demographics
NPI:1174700546
Name:CONLEY, DEANGELA (MA CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:DEANGELA
Middle Name:
Last Name:CONLEY
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3306
Mailing Address - Country:US
Mailing Address - Phone:304-855-8425
Mailing Address - Fax:
Practice Address - Street 1:506 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3306
Practice Address - Country:US
Practice Address - Phone:304-792-2073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01042472235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0152737000Medicaid