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General NPI Number Information
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NPI Number | 1932884186
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Entity Type | Organization
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Legal Business Name | RESILIENT YOUTH, PLLC
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Dates
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Enumeration Date | 06/15/2023
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Last Update Date | 08/15/2023
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Provider Practice Location Address
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Address Line | 402 CHURCH ST STE 2
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City | SUMMERSVILLE
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State | WV
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Zip | 26651-1495
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Country | US
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Telephone | 304-719-9701
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 211
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City | MOUNT NEBO
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State | WV
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Zip | 26679-0211
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Country | US
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Telephone | 304-719-9701
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Fax |
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Authorized Official
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Title or Position | OWNER/SCHOOL PSYCHOLOGIST
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Name | MYRA M MOORE
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Credential |
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Telephone | 304-719-9701
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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