Healthcare Provider Details

I. General information

NPI: 1669468971
Provider Name (Legal Business Name): WALTER FREDRICK SIAS MSW LICSW BCD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 20
QUIET DELL WV
26408
US

IV. Provider business mailing address

RR 2 BOX 233B
MOUNT CLARE WV
26408-9719
US

V. Phone/Fax

Practice location:
  • Phone: 304-622-6404
  • Fax: 304-622-6404
Mailing address:
  • Phone: 304-622-6404
  • Fax: 304-622-6404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00451601
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: