Healthcare Provider Details

I. General information

NPI: 1144629312
Provider Name (Legal Business Name): RANCE A BERRY II II LPC, CSOTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 OHIO AVE
DUNBAR WV
25064-3019
US

IV. Provider business mailing address

1021 QUARRIER ST STE 414
CHARLESTON WV
25301-2338
US

V. Phone/Fax

Practice location:
  • Phone: 866-308-2307
  • Fax: 855-314-6877
Mailing address:
  • Phone: 304-340-3676
  • Fax: 304-340-3688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2132
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: