=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609932623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GAIL A. SHADE, M.A., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 640 FAIRFAX ST SUITE #3
-----------------------------------------------------
City | BERKELEY SPRINGS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25411-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-258-5353
-----------------------------------------------------
Fax | 304-258-9313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 903
-----------------------------------------------------
City | BERKELEY SPRINGS
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25411-0903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-258-5353
-----------------------------------------------------
Fax | 304-258-9313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | MRS. GAIL ARLENE SHADE
-----------------------------------------------------
Credential | BSW, MA. PSYD
-----------------------------------------------------
Telephone | 304-258-5353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 1001
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------