Healthcare Provider Details

I. General information

NPI: 1548473903
Provider Name (Legal Business Name): MARK VINCENT SUNDSTROM M.S.,LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W MAPLE AVE
FAYETTEVILLE WV
25840-1413
US

IV. Provider business mailing address

209 W MAPLE AVE
FAYETTEVILLE WV
25840-1413
US

V. Phone/Fax

Practice location:
  • Phone: 304-574-2100
  • Fax: 304-574-2151
Mailing address:
  • Phone: 304-574-2100
  • Fax: 304-574-2151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00450472
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: