Healthcare Provider Details

I. General information

NPI: 1184042657
Provider Name (Legal Business Name): NOLA GLENORA GUM MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 CENTER ST
PRINCETON WV
24740-2931
US

IV. Provider business mailing address

205 CENTER ST
PRINCETON WV
24740-2931
US

V. Phone/Fax

Practice location:
  • Phone: 304-431-2424
  • Fax: 304-431-3443
Mailing address:
  • Phone: 304-431-2424
  • Fax: 304-431-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCP00943432
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: