Healthcare Provider Details

I. General information

NPI: 1336023712
Provider Name (Legal Business Name): LAURENS WISH ADDICTION TRIAGE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2025
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 SCOTT AVE STE 301
MORGANTOWN WV
26508-8857
US

IV. Provider business mailing address

20 SCOTT AVE STE 301
MORGANTOWN WV
26508-8857
US

V. Phone/Fax

Practice location:
  • Phone: 304-241-4000
  • Fax: 304-212-5141
Mailing address:
  • Phone: 304-241-4000
  • Fax: 304-212-5141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRANDON M WISE
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 304-282-7632