Provider Demographics
NPI:1255526786
Name:FORTNEY, RITA GRACE (MA CCCSP)
Entity type:Individual
Prefix:MRS
First Name:RITA
Middle Name:GRACE
Last Name:FORTNEY
Suffix:
Gender:F
Credentials:MA CCCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC63 BOX 936
Mailing Address - Street 2:
Mailing Address - City:PANTHER
Mailing Address - State:WV
Mailing Address - Zip Code:24872
Mailing Address - Country:US
Mailing Address - Phone:304-938-3053
Mailing Address - Fax:
Practice Address - Street 1:ROUTE 10
Practice Address - Street 2:WYOMING COUNTY BOARD OF EDUCATION
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874
Practice Address - Country:US
Practice Address - Phone:304-732-6262
Practice Address - Fax:304-732-8569
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVASHA12048761235Z00000X
WVWVSLP0921235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9409126000Medicaid