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General NPI Number Information
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NPI Number | 1710391057
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Entity Type | Organization
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Legal Business Name | DEVELOPMENTAL EVOLUTION, LLC
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Dates
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Enumeration Date | 06/15/2014
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Last Update Date | 06/15/2014
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Provider Practice Location Address
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Address Line | 667 HUYETT RD
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City | CHARLES TOWN
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State | WV
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Zip | 25414-5378
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Country | US
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Telephone | 304-725-4160
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Fax |
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Provider Business Mailing Address
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Address Line | 44 PADDOCK PL
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City | CHARLES TOWN
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State | WV
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Zip | 25414-5329
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Country | US
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Telephone | 304-725-4160
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MICHAEL SHOR
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Credential | MSW
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Telephone | 304-725-4160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | BP00944336
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License Number State | WV
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