Healthcare Provider Details

I. General information

NPI: 1972713121
Provider Name (Legal Business Name): CHRYSALIS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 UNDERCLIFF TER
PRINCETON WV
24740-2174
US

IV. Provider business mailing address

160 UNDERCLIFF TER
PRINCETON WV
24740-2174
US

V. Phone/Fax

Practice location:
  • Phone: 304-425-6110
  • Fax: 304-487-6199
Mailing address:
  • Phone: 304-425-6110
  • Fax: 304-487-6199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number136
License Number StateWV

VIII. Authorized Official

Name: TWYLA HERSMAN
Title or Position: LPC
Credential: MA
Phone: 304-425-6110