Healthcare Provider Details

I. General information

NPI: 1265112247
Provider Name (Legal Business Name): HOMETOWN PROFESSIONAL COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 MARSHALL HIGHWAY
BRADSHAW WV
24817
US

IV. Provider business mailing address

2004 OOZLEY BRANCH RD
PAYNESVILLE WV
24873-2703
US

V. Phone/Fax

Practice location:
  • Phone: 304-320-5544
  • Fax:
Mailing address:
  • Phone: 304-967-7813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ANGGUNA R ROWE
Title or Position: OWNER
Credential: M.ED. NCC, LPC
Phone: 304-320-5544