Provider Demographics
NPI:1598338659
Name:PROFESSIONAL CARE CASE MANAGEMENT, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL CARE CASE MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:304-635-7740
Mailing Address - Street 1:19 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3125
Mailing Address - Country:US
Mailing Address - Phone:304-635-7740
Mailing Address - Fax:304-635-7742
Practice Address - Street 1:19 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3125
Practice Address - Country:US
Practice Address - Phone:304-635-7740
Practice Address - Fax:304-635-7742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-17
Last Update Date:2021-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1154709095Medicaid
WV15787179149Medicaid
WV1700409067Medicaid