Provider Demographics
NPI:1649539396
Name:RADCLIFFE, HEATHER ANNE (LICSW ACSW)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANNE
Last Name:RADCLIFFE
Suffix:
Gender:F
Credentials:LICSW ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 PROFESSIONAL PL STE 102103
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-0258
Mailing Address - Country:US
Mailing Address - Phone:304-848-5770
Mailing Address - Fax:304-848-0980
Practice Address - Street 1:65 PROFESSIONAL PL STE 102103
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-0258
Practice Address - Country:US
Practice Address - Phone:304-848-5770
Practice Address - Fax:304-848-0980
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP009410151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1649539396Medicaid