Basic Information
| Provider Information | |||||||||
| NPI: | 1023311933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARVEY | ||||||||
| FirstName: | NEELY | ||||||||
| MiddleName: | SNEAD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ED.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 FAYETTE AVENUE | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045741176 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 FAYETTE AVE | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258401219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045741176 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2010 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 7755 | WV | Y | Behavioral Health & Social Service Providers | Psychologist | School |
ID Information
| ID | Type | State | Issuer | Description | 012397000/4802006000 | 05 | WV | MEDICAID |