Healthcare Provider Details

I. General information

NPI: 1518303056
Provider Name (Legal Business Name): LOTUS PLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 05/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 GREENBAG ROAD, UNIT E7
MORGANTOWN WV
26501-2411
US

IV. Provider business mailing address

5000 GREENBAG ROAD, UNIT E7 MOUNTAINEER MALL
MORGANTOWN WV
26501
US

V. Phone/Fax

Practice location:
  • Phone: 304-612-1582
  • Fax:
Mailing address:
  • Phone: 304-612-1582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1896
License Number StateWV

VIII. Authorized Official

Name: MS. LINDA SUE SHREVE
Title or Position: PSYCHOTHERAPIST
Credential: MS, LPC, NCC
Phone: 304-612-1582