Provider Demographics
NPI:1942610522
Name:BOARDMAN, REBECCA E (LICSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:E
Last Name:BOARDMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2157 GREENBRIER ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-9623
Mailing Address - Country:US
Mailing Address - Phone:304-344-5924
Mailing Address - Fax:304-356-3239
Practice Address - Street 1:511 MORRIS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1326
Practice Address - Country:US
Practice Address - Phone:304-341-0511
Practice Address - Fax:304-341-0499
Is Sole Proprietor?:No
Enumeration Date:2014-05-05
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVCP009427401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005355002Medicaid
WV9122432Medicare Oscar/Certification