Provider Demographics
NPI:1134131329
Name:KODRICH, MICHAEL A (LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:KODRICH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 EMERSON AVE
Mailing Address - Street 2:SUITE 2-B
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104-1849
Mailing Address - Country:US
Mailing Address - Phone:304-420-0940
Mailing Address - Fax:304-865-2214
Practice Address - Street 1:3501 EMERSON AVE
Practice Address - Street 2:SUITE 2-B
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26104-1849
Practice Address - Country:US
Practice Address - Phone:304-420-0940
Practice Address - Fax:304-865-2214
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1197101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVY288393OtherHEALTH PLAN PIN NUMBER
WV096167OtherVALUE OPTIONS PIN NUMBER
WV180073OtherCOMPSYCH PIN NUMBER
WV2031476OtherCIGNA HEALTH CARE PIN NUM
WV000000234570OtherANTHEM PIN NUMBER
WV7227387OtherAETNA PROVIDER PIN NUMBER