=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831376748
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDITH JACQUELINE HARTSOG MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2008
-----------------------------------------------------
Last Update Date | 01/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 VETERANS AVE
-----------------------------------------------------
City | BECKLEY
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25801-6444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-255-2121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 204
-----------------------------------------------------
City | GHENT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25843-0204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-787-4406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | AP00213502
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------