Healthcare Provider Details

I. General information

NPI: 1437145331
Provider Name (Legal Business Name): THOMAS ODELL DUVALL PHD, LMHC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 FCI LN
GLENVILLE WV
26351-9500
US

IV. Provider business mailing address

PO BOX 5000
GLENVILLE WV
26351-5000
US

V. Phone/Fax

Practice location:
  • Phone: 304-626-2500
  • Fax: 304-626-2604
Mailing address:
  • Phone: 304-626-2500
  • Fax: 304-626-2604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC005142
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH8470
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY9866
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: