=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851952493
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA J PETERS LGSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2019
-----------------------------------------------------
Last Update Date | 03/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 PROFESSIONAL PL STE 101
-----------------------------------------------------
City | BRIDGEPORT
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26330-4599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-513-3495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 HOSPITAL PLZ
-----------------------------------------------------
City | CLARKSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26301-9321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-623-5661
-----------------------------------------------------
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 | BP00944565
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | DP00944565
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------