Healthcare Provider Details

I. General information

NPI: 1730574013
Provider Name (Legal Business Name): ADULT AND YOUTH SERVICES, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HARRISON AVE. SUITE 121
ELKINS WV
26241-3392
US

IV. Provider business mailing address

PO BOX 44
DAVIS WV
26260-0044
US

V. Phone/Fax

Practice location:
  • Phone: 304-636-4200
  • Fax: 304-636-4200
Mailing address:
  • Phone: 304-257-8232
  • Fax: 304-636-4200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2304-8074
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number999
License Number StateWV

VIII. Authorized Official

Name: DR. DANA A NUGENT
Title or Position: OWNER/PSYCHOLOGIST
Credential: ED. D.
Phone: 304-257-8232