Basic Information
Provider Information | |||||||||
NPI: | 1942610522 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOARDMAN | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LICSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2157 GREENBRIER ST | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 253119623 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043445924 | ||||||||
FaxNumber: | 3043563239 | ||||||||
Practice Location | |||||||||
Address1: | 511 MORRIS ST | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 253011326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043410511 | ||||||||
FaxNumber: | 3043410499 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2014 | ||||||||
LastUpdateDate: | 10/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CP00942740 | WV | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 0005355002 | 05 | WV |   | MEDICAID |