| Community Care Of West Virginia, Inc. | |
|
65 Professional Pl Ste 101 Bridgeport WV 26330-1889 | |
| (304) 848-5770 | |
| (304) 848-0890 |
| Full Name | Community Care Of West Virginia, Inc. |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 65 Professional Pl Ste 101, Bridgeport, West Virginia |
| Authorized Official Name and Position | Dora L Potasnik (CREDENTIALING COORDINATOR) |
| Authorized Official Contact | 3043177275 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Community Care Of West Virginia, Inc. 65 Professional Pl Ste 101 Bridgeport WV 26330-1889 Ph: (304) 848-5770 | Community Care Of West Virginia, Inc. 65 Professional Pl Ste 101 Bridgeport WV 26330-1889 Ph: (304) 848-5770 |
| NPI Number | 1144811290 |
|---|---|
| Provider Enumeration Date | 02/01/2021 |
| Last Update Date | 02/17/2021 |
| Certification Date | 02/02/2021 |
| Medicare PECOS PAC ID | 0446232987 |
|---|---|
| Medicare Enrollment ID | O20210331002097 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1144811290 | NPI | - | NPPES |
| 516 | Other | WV | STATE OF WV DEPARTMENT OF HEALTH AND HUMAN SERVICES BEHAVIORAL HEALTH LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| Provider Name | Heather A Radcliffe |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1649539396 PECOS PAC ID: 1951557115 Enrollment ID: I20120803000706 |
| Provider Name | Liam Patrick Condon |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1770080186 PECOS PAC ID: 8527323518 Enrollment ID: I20180522000973 |
| Provider Name | Benjamin Douglas Hines |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1144664863 PECOS PAC ID: 2860795242 Enrollment ID: I20180817002125 |
| Provider Name | Dietra Michelle Savage |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1457917064 PECOS PAC ID: 2466788484 Enrollment ID: I20190730001111 |
| Provider Name | Alyssa Vougas |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1235287798 PECOS PAC ID: 2567364995 Enrollment ID: I20210329000387 |
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