Provider Demographics
NPI:1710481916
Name:BOARD, MEGHAN NICOLE
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:NICOLE
Last Name:BOARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MATHEWS RD
Mailing Address - Street 2:
Mailing Address - City:RED HOUSE
Mailing Address - State:WV
Mailing Address - Zip Code:25168-7656
Mailing Address - Country:US
Mailing Address - Phone:304-419-2241
Mailing Address - Fax:
Practice Address - Street 1:505 LEON SULLIVAN WAY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1216
Practice Address - Country:US
Practice Address - Phone:304-419-2241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0900103-SUPV1041C0700X
WVDP009447491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical