Provider Demographics
NPI:1720444854
Name:SHRIVER, REBECCA MARIE (LGSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MARIE
Last Name:SHRIVER
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:MARIE
Other - Last Name:NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
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:304-848-0890
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:304-848-0890
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00944794104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker