=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982974416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTERN PANHANDLE MENTAL HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2011
-----------------------------------------------------
Last Update Date | 09/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 S WATER ST
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-4241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-263-8954
-----------------------------------------------------
Fax | 304-264-0763
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 S WATER ST
-----------------------------------------------------
City | MARTINSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25401-4241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-263-8954
-----------------------------------------------------
Fax | 304-264-0763
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. G PAUL MACOM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-263-8954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 1022-6441
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------