Provider Demographics
NPI:1104003524
Name:ATKINSON, JOHN RUSSELL (MS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RUSSELL
Last Name:ATKINSON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 38TH ST.
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-2741
Mailing Address - Country:US
Mailing Address - Phone:304-295-9243
Mailing Address - Fax:304-428-4500
Practice Address - Street 1:1007 38TH ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-2741
Practice Address - Country:US
Practice Address - Phone:304-295-9243
Practice Address - Fax:304-428-4500
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV309103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0165376000Medicaid