Provider Demographics
NPI:1831317866
Name:MCCLURE, SALLY BRUNNER (LSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:BRUNNER
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ARROWHEAD DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:25213
Mailing Address - Country:US
Mailing Address - Phone:304-344-5924
Mailing Address - Fax:304-344-3503
Practice Address - Street 1:2157 GREENBRIER STREET
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311
Practice Address - Country:US
Practice Address - Phone:304-344-5924
Practice Address - Fax:304-344-3503
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP00939365101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)