Healthcare Provider Details

I. General information

NPI: 1083103212
Provider Name (Legal Business Name): DARICE RENEE YERKOVICH LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N WEDGE ST
BRIDGEPORT WV
26330-2022
US

IV. Provider business mailing address

235 HIGH ST STE 322
MORGANTOWN WV
26505-5455
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-0344
  • Fax:
Mailing address:
  • Phone: 681-214-0025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberBP00945134
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberBP00945134
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00945134
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberBP00945134
License Number StateWV
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberBP00945134
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: