Basic Information
| Provider Information | |||||||||
| NPI: | 1720444854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHRIVER | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | L.G.S.W | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NORMAN | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 65 PROFESSIONAL PL STE 102103 | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263300258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048485770 | ||||||||
| FaxNumber: | 3048480890 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 PROFESSIONAL PL STE 102103 | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263300258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048485770 | ||||||||
| FaxNumber: | 3048480890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2016 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | BP00944794 | WV | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.