MEDICARE: ADVANTAGE

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	251S00000X	Community/Behavioral Health Agency	03-611	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2245-0179	OTHER		WV STATE TAX DEPARTMENT BUSINESS REGISTRATION

General Provider Information

NPI Number	:	1831543289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANTAGE

Provider Business Mailing Address
First Line	:	606 FORT HILL DR
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25314-1070
Country	:	US
Telephone Number	:	304-346-8829
Fax Number	:	304-346-8829

Provider Business Practice Location Address
First Line	:	2402 KANAWHA BLVD E
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25311-2323
Country	:	US
Telephone Number	:	304-389-5535
Fax Number	:	304-346-8829

Authorized Official
Title or Position	:	ADDICTIONS SPECIALIST
Name	:	DR. MARIE ESTEP
Credential	:	PH.D, AADC
Telephone Number	:	304-346-8829

Provider Enumeration Date	:	04/21/2016
Last Update Date	:	04/21/2016

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Directions to “ADVANTAGE ” Practice Location

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