Provider Demographics
NPI:1003952250
Name:WHEATCRAFT, BEVERLY J (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:J
Last Name:WHEATCRAFT
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 5 BOX 289O
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312-9605
Mailing Address - Country:US
Mailing Address - Phone:304-444-7086
Mailing Address - Fax:304-965-3176
Practice Address - Street 1:600 SHREWSBURY ST
Practice Address - Street 2:BOX 8
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1230
Practice Address - Country:US
Practice Address - Phone:304-444-7086
Practice Address - Fax:304-965-3176
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009403261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810008214Medicaid
WV001995674OtherMS BCBS