Provider Demographics
NPI:1093899056
Name:GARRISON, LILBURN H II
Entity Type:Individual
Prefix:
First Name:LILBURN
Middle Name:H
Last Name:GARRISON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1748
Mailing Address - Country:US
Mailing Address - Phone:304-842-8822
Mailing Address - Fax:
Practice Address - Street 1:243 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1748
Practice Address - Country:US
Practice Address - Phone:304-842-8852
Practice Address - Fax:304-842-8853
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVCP004544431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVSW32761Medicare PIN