MEDICARE: IMAGINE STATION WV LLC

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	101YP2500X	Professional Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1124273065	OTHER		NPI NUMBER

General Provider Information

NPI Number	:	1508520966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMAGINE STATION WV LLC

Provider Business Mailing Address
First Line	:	709 3RD AVE
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-1421
Country	:	US
Telephone Number	:	304-544-2417
Fax Number	:

Provider Business Practice Location Address
First Line	:	709 3RD AVE
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-1421
Country	:	US
Telephone Number	:	304-633-7751
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CANDACE D LAYNE
Credential	:	LPC
Telephone Number	:	304-544-2417

Provider Enumeration Date	:	10/22/2021
Last Update Date	:	08/08/2022

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Directions to “IMAGINE STATION WV LLC ” Practice Location

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