=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194424101
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY LORAINE EHRENBERG MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2023
-----------------------------------------------------
Last Update Date | 05/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1586 WINCHESTER AVE
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25405-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-267-0818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43 SOUTHWINDS DR
-----------------------------------------------------
City | CHARLES TOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25414-3976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-897-9827
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SW012316491
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | BP00946563
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------