Healthcare Provider Details

I. General information

NPI: 1679747893
Provider Name (Legal Business Name): MARY ANN SHIRES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 INDUSTRIAL PARK RD
MAXWELTON WV
24957-8066
US

IV. Provider business mailing address

1305 WEBSTER RD
SUMMERSVILLE WV
26651-1125
US

V. Phone/Fax

Practice location:
  • Phone: 304-497-0500
  • Fax:
Mailing address:
  • Phone: 304-872-6503
  • Fax: 304-872-5415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCP00080591
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: