Healthcare Provider Details

I. General information

NPI: 1235677725
Provider Name (Legal Business Name): EUGENIE PROVOSTY TAYLOR LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 LEON SULLIVAN WAY SUITE 300
CHARLESTON WV
25301-2402
US

IV. Provider business mailing address

16 LEON SULLIVAN WAY
CHARLESTON WV
25301-2402
US

V. Phone/Fax

Practice location:
  • Phone: 304-346-9689
  • Fax:
Mailing address:
  • Phone: 304-346-9689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberDP00939976
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: