1144456161 NPI number — MS. GERALYN MARIE CONWAY LCSW

Table of content: MS. GERALYN MARIE CONWAY LCSW (NPI 1144456161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144456161 NPI number — MS. GERALYN MARIE CONWAY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONWAY
Provider First Name:
GERALYN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144456161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
165 PEPPERS FERRY RD
Provider Second Line Business Mailing Address:
WYTHEVILLE CBOC
Provider Business Mailing Address City Name:
WYTHEVILLE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24382
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-223-5449
Provider Business Mailing Address Fax Number:
276-223-5455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WYTHEVILLE CBOC
Provider Second Line Business Practice Location Address:
100 PEPPERS FERRY RD
Provider Business Practice Location Address City Name:
WYTHEVILLE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24243-3121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-674-1377
Provider Business Practice Location Address Fax Number:
540-674-1351
Provider Enumeration Date:
06/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  0904007099 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1144456161 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com