Healthcare Provider Details

I. General information

NPI: 1003665704
Provider Name (Legal Business Name): F.A.I.T.H BEHAVIORAL SUPPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 WASHINGTON ST W STE 202
CHARLESTON WV
25302-2230
US

IV. Provider business mailing address

PO BOX 1105
DUNBAR WV
25064-7105
US

V. Phone/Fax

Practice location:
  • Phone: 304-951-7736
  • Fax:
Mailing address:
  • Phone: 304-550-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: YVONNE SHERII LEE
Title or Position: CEO/CASE MANAGER
Credential: PHD, LGSW
Phone: 304-343-0044