Provider Demographics
NPI:1205058773
Name:FAMILY SERVICE DIV OF GOODWILL INDUSTRIES OF KYOWVA AREA, INC.
Entity type:Organization
Organization Name:FAMILY SERVICE DIV OF GOODWILL INDUSTRIES OF KYOWVA AREA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-523-9454
Mailing Address - Street 1:1102 MEMORIAL BLVD. W.
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701
Mailing Address - Country:US
Mailing Address - Phone:304-523-9545
Mailing Address - Fax:304-525-7038
Practice Address - Street 1:1102 MEMORIAL BLVD. W.
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701
Practice Address - Country:US
Practice Address - Phone:304-523-9545
Practice Address - Fax:304-525-7038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1678101YP2500X
WV27907101Y00000X
101YP2500X
WV251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1851371058OtherNPI GENERAL PRACTICE