Healthcare Provider Details

I. General information

NPI: 1932288107
Provider Name (Legal Business Name): 7TH AVE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 TEMPLE ST
HINTON WV
25951
US

IV. Provider business mailing address

HC 74 BOX 284
HINTON WV
25951-9121
US

V. Phone/Fax

Practice location:
  • Phone: 304-673-1913
  • Fax:
Mailing address:
  • Phone: 394-673-1913
  • Fax: 304-466-1676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number889
License Number StateWV

VIII. Authorized Official

Name: LYNN M SANDERS
Title or Position: OWNER
Credential: MA
Phone: 304-673-1913