MEDICARE: MRS. GAIL ARLENE SHADE LPC

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	1001	WV

General Provider Information

NPI Number	:	1912084385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. GAIL ARLENE SHADE LPC

Provider Business Mailing Address
First Line	:	PO BOX 903
Second Line	:
City	:	BERKELEY SPRINGS
State	:	WV
Zip	:	25411-0903
Country	:	US
Telephone Number	:	304-258-5353
Fax Number	:	304-258-9313

Provider Business Practice Location Address
First Line	:	640 FAIRFAX ST
Second Line	:	SUITE #3
City	:	BERKELEY SPRINGS
State	:	WV
Zip	:	25411-1622
Country	:	US
Telephone Number	:	304-258-5353
Fax Number	:	304-258-9313

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

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	07/08/2007

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