=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528238425
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. MARY PRENTICE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2008
-----------------------------------------------------
Last Update Date | 03/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 SULLIVAN RD
-----------------------------------------------------
City | GLEN MORGAN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25813-7600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-256-4500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 136 SULLIVAN RD
-----------------------------------------------------
City | GLEN MORGAN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25813-7600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-256-4500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 10049
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------