Healthcare Provider Details

I. General information

NPI: 1639542442
Provider Name (Legal Business Name): SUSAN MILLHAM LICSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2015
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 COOMBS FARM RD STE 202
MORGANTOWN WV
26508-0803
US

IV. Provider business mailing address

7000 COOMBS FARM RD STE 202
MORGANTOWN WV
26508-0803
US

V. Phone/Fax

Practice location:
  • Phone: 304-435-3494
  • Fax:
Mailing address:
  • Phone: 304-435-3494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberDP00944194
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: SUSAN MILLHAM
Title or Position: OWNER
Credential: MSW, LICSW
Phone: 304-435-3494