MEDICARE: PSYCHOLOGICAL CONSULTATION AND ASSESSMENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1295869840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOLOGICAL CONSULTATION AND ASSESSMENT

Provider Business Mailing Address
First Line	:	202 GLASS DR
Second Line	:
City	:	CROSS LANES
State	:	WV
Zip	:	25313-1319
Country	:	US
Telephone Number	:	304-776-7230
Fax Number	:	304-776-7247

Provider Business Practice Location Address
First Line	:	202 GLASS DR
Second Line	:
City	:	CROSS LANES
State	:	WV
Zip	:	25313-1319
Country	:	US
Telephone Number	:	304-776-7230
Fax Number	:	304-776-7247

Authorized Official
Title or Position	:	OWNER PRESIDENT PSYCHOLOGIST
Name	:	MR. RICHARD WORKMAN
Credential	:	MA
Telephone Number	:	304-776-7230

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	08/22/2020

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