=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982260030
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL MONSMA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2019
-----------------------------------------------------
Last Update Date | 05/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 MADDEX DRIVE
-----------------------------------------------------
City | SHEPHERDSTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-620-6365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 595 CHERRY HILL FARM DRIVE
-----------------------------------------------------
City | KEARNEYSVILLE
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-620-6365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EMPLOYEE
-----------------------------------------------------
Name | MR. MICHAEL KENT MONSMA
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 304-620-6365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------