Healthcare Provider Details

I. General information

NPI: 1609585249
Provider Name (Legal Business Name): SHANECE EDEN LYNN FORGE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MON HEALTH MEDICAL PARK DR STE 1202
MORGANTOWN WV
26505-1143
US

IV. Provider business mailing address

1000 MON HEALTH MEDICAL PARK DR STE 1202
MORGANTOWN WV
26505-1143
US

V. Phone/Fax

Practice location:
  • Phone: 304-599-1975
  • Fax: 304-599-2705
Mailing address:
  • Phone: 304-599-1975
  • Fax: 304-599-2705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3006
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: