Basic Information
| Provider Information | |||||||||
| NPI: | 1376637397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOTAK | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1128 | ||||||||
| Address2: | 1014 JOHNSTOWN ROAD | ||||||||
| City: | BECKLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258021128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042524433 | ||||||||
| FaxNumber: | 3042521703 | ||||||||
| Practice Location | |||||||||
| Address1: | 1014 JOHNSTOWN ROAD | ||||||||
| Address2: | |||||||||
| City: | BECKLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258014940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042524433 | ||||||||
| FaxNumber: | 3042521703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 436 | WV | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0116820000 | 05 | WV | MEDICAID | 3810004530 | 05 | WV | MEDICAID |