Provider Demographics
NPI:1609585249
Name:FORGE, SHANECE EDEN LYNN (MS)
Entity Type:Individual
Prefix:
First Name:SHANECE
Middle Name:EDEN LYNN
Last Name:FORGE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MON HEALTH MEDICAL PARK DR STE 1202
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-1143
Mailing Address - Country:US
Mailing Address - Phone:304-599-1975
Mailing Address - Fax:304-599-2705
Practice Address - Street 1:1000 MON HEALTH MEDICAL PARK DR STE 1202
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-1143
Practice Address - Country:US
Practice Address - Phone:304-599-1975
Practice Address - Fax:304-599-2705
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV774101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor