Healthcare Provider Details

I. General information

NPI: 1346734803
Provider Name (Legal Business Name): PATRTNERSHIP OF AFRICAN AMERICAN CHURCHES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 KANAWHA BLVD W
CHARLESTON WV
25387-2533
US

IV. Provider business mailing address

1514 KANAWHA BLVD W
CHARLESTON WV
25387-2533
US

V. Phone/Fax

Practice location:
  • Phone: 304-768-7688
  • Fax: 304-768-7647
Mailing address:
  • Phone: 304-768-7688
  • Fax: 304-768-7647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: EDNA GREEN
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 304-768-7688