=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174829345
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRONG THROUGH OUR PLAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2011
-----------------------------------------------------
Last Update Date | 02/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 LARRY JOE HARLESS DR.
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25621-1385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-664-3986
-----------------------------------------------------
Fax | 304-664-2997
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 1385 202 LARRY JOE HARLESS DR.
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25621-1385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-664-3986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD OF DIRECTORS, CHAIRPERSON
-----------------------------------------------------
Name | JANET PETERWORTH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-393-1481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------