Provider Demographics
NPI:1669468971
Name:SIAS, WALTER FREDRICK (MSW LICSW BCD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:FREDRICK
Last Name:SIAS
Suffix:
Gender:M
Credentials:MSW LICSW BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 2 BOX 233B
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLARE
Mailing Address - State:WV
Mailing Address - Zip Code:26408-9719
Mailing Address - Country:US
Mailing Address - Phone:304-622-6404
Mailing Address - Fax:304-622-6404
Practice Address - Street 1:ROUTE 20
Practice Address - Street 2:
Practice Address - City:QUIET DELL
Practice Address - State:WV
Practice Address - Zip Code:26408
Practice Address - Country:US
Practice Address - Phone:304-622-6404
Practice Address - Fax:304-622-6404
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP004516011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVSW00362Medicare ID - Type Unspecified