=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013946920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSIMED OASIS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2006
-----------------------------------------------------
Last Update Date | 06/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 PEYTON WAY
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25309-8572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-720-8466
-----------------------------------------------------
Fax | 304-720-8463
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7310
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25356-0310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-776-7606
-----------------------------------------------------
Fax | 304-776-7636
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF FINANCE
-----------------------------------------------------
Name | MS. FREDDIE V SIZEMORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-776-7606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------