Basic Information
| Provider Information | |||||||||
| NPI: | 1407115439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURACCHIO | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | RICARDO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261013803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044851721 | ||||||||
| FaxNumber: | 3044859203 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261013803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044851721 | ||||||||
| FaxNumber: | 3044859203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 05/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | AP00943569 | WV | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | AP00943569 | 01 | WV | LSW | OTHER |