Basic Information
| Provider Information | |||||||||
| NPI: | 1568518017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DISS | ||||||||
| FirstName: | SYLVIA | ||||||||
| MiddleName: | RENNINGS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 EOFF ST | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260033823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042348663 | ||||||||
| FaxNumber: | 3042348960 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 12TH ST | ||||||||
| Address2: | STE. 222 | ||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260033279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042320232 | ||||||||
| FaxNumber: | 3042320035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | DP00453160 | WV | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 001708589 | 01 | WV | MOUNTAIN STATE BLUE CROSS | OTHER | Y307981B | 01 | WV | MAGELLAN | OTHER |