Provider Demographics
NPI:1508520966
Name:IMAGINE STATION WV LLC
Entity Type:Organization
Organization Name:IMAGINE STATION WV LLC
Other - Org Name:IMAGINE COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:304-544-2417
Mailing Address - Street 1:709 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-1421
Mailing Address - Country:US
Mailing Address - Phone:304-544-2417
Mailing Address - Fax:
Practice Address - Street 1:709 3RD AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-1421
Practice Address - Country:US
Practice Address - Phone:304-633-7751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMAGINATION STATION WV LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-22
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1124273065OtherNPI NUMBER