MEDICARE: ELIZABETH WALLING LGSW

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	1041C0700X	Clinical Social Worker	BP00945911	WV

General Provider Information

NPI Number	:	1316511181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH WALLING LGSW

Provider Business Mailing Address
First Line	:	235 HIGH ST STE 816
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26505-5448
Country	:	US
Telephone Number	:	304-288-3504
Fax Number	:	304-777-4487

Provider Business Practice Location Address
First Line	:	235 HIGH ST STE 816
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26505-5448
Country	:	US
Telephone Number	:	304-288-3504
Fax Number	:	304-777-4487

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2021
Last Update Date	:	05/17/2021

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