Healthcare Provider Details

I. General information

NPI: 1205304284
Provider Name (Legal Business Name): DESIREE DIENSTAG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 DARE RD
YORKTOWN VA
23692-2716
US

IV. Provider business mailing address

1912 JAMESTOWN RD
WILLIAMSBURG VA
23185-2379
US

V. Phone/Fax

Practice location:
  • Phone: 757-898-0300
  • Fax:
Mailing address:
  • Phone: 800-356-4049
  • Fax: 800-892-0648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: