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Mental Retardation and Developmental Disabilities

Parkersburg, West Virginia

Provider NPI: 1538295829

Provider Information:
Gender: M
Not Sole Proprietor

Practice Location:
Tel: 304-485-1721  Fax: 304-485-6710

Business Mailing Address:
Tel: 304-485-5578  Fax: --

Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
Y103TM1800XBehavioral Health & Social Service Providers
Mental Retardation & Developmental Disabilities

Other Provider Identifiers:

Code values:
01, Other | 02, Medicare Upin | 04, Medicare Id-Type Unspecified
05, Medicaid | 06, Medicare Oscar/Certification | 07, Medicare NSC | 08, Medicare Pin


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