=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497812713
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BURT ALLEN PRICE MSW,LGSW,CCAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 448 LEONARD AVE
-----------------------------------------------------
City | FAIRMONT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26554-3843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-366-7174
-----------------------------------------------------
Fax | 304-366-7419
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 494 LYNCH RD
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26501-7787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-366-7174
-----------------------------------------------------
Fax | 304-366-7419
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | BP00938488
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------