Healthcare Provider Details

I. General information

NPI: 1447361340
Provider Name (Legal Business Name): DONALD WORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 BROWN AVE
WESTON WV
26452-2177
US

IV. Provider business mailing address

5 BROWN AVE
WESTON WV
26452-2177
US

V. Phone/Fax

Practice location:
  • Phone: 304-269-3923
  • Fax: 304-269-9733
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number934
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number27065
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number27065
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: