=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871804161
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICKI DIANNE LEMINE LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2010
-----------------------------------------------------
Last Update Date | 07/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1063 MAPLE DR SUITE 4 B
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26505-2848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-276-8261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 714 VENTURE DR #218
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26508-7306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-276-8261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | DP00452261
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------