Provider Demographics
NPI:1639271836
Name:SALAMACHA, LABERTA S (MA LICENSED PSYCHOLO)
Entity Type:Individual
Prefix:MRS
First Name:LABERTA
Middle Name:S
Last Name:SALAMACHA
Suffix:
Gender:F
Credentials:MA LICENSED PSYCHOLO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 536
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560
Mailing Address - Country:US
Mailing Address - Phone:304-737-3036
Mailing Address - Fax:304-757-5505
Practice Address - Street 1:4031 TEAYS VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560
Practice Address - Country:US
Practice Address - Phone:304-757-3036
Practice Address - Fax:304-757-5505
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV624101Y00000X
WV540103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4293426OtherAETNA
WV0163636000Medicaid