Healthcare Provider Details

I. General information

NPI: 1013946920
Provider Name (Legal Business Name): PSIMED OASIS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PEYTON WAY
CHARLESTON WV
25309-8572
US

IV. Provider business mailing address

PO BOX 7310
CHARLESTON WV
25356-0310
US

V. Phone/Fax

Practice location:
  • Phone: 304-720-8466
  • Fax: 304-720-8463
Mailing address:
  • Phone: 304-776-7606
  • Fax: 304-776-7636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. FREDDIE V SIZEMORE
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 304-776-7606