=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578628228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI-COUNTY PASTORAL COUNSELING SERVICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 W BURKE ST
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-3322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-263-6205
-----------------------------------------------------
Fax | 304-267-7082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 W BURKE ST
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-3322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-263-6205
-----------------------------------------------------
Fax | 304-267-7082
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR & SUPERVISOR
-----------------------------------------------------
Name | MR. WARREN WAYNE WATTS
-----------------------------------------------------
Credential | M.DIV.
-----------------------------------------------------
Telephone | 304-263-6205
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 294
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------