Provider Demographics
NPI:1194820118
Name:INTENSIVE TRAUMA THERAPY INC
Entity Type:Organization
Organization Name:INTENSIVE TRAUMA THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANTT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD ATRBC
Authorized Official - Phone:304-291-2912
Mailing Address - Street 1:314 SCOTT AVENUE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508
Mailing Address - Country:US
Mailing Address - Phone:304-291-2912
Mailing Address - Fax:304-291-2918
Practice Address - Street 1:314 SCOTT AVENUE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508
Practice Address - Country:US
Practice Address - Phone:304-291-2912
Practice Address - Fax:304-291-2918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC001898103TC1900X
WVDP009390591041C0700X
WVDP009426231041C0700X
79001221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Not Answered221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty