Provider Demographics
NPI:1144456161
Name:CONWAY, GERALYN MARIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:GERALYN
Middle Name:MARIE
Last Name:CONWAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 PEPPERS FERRY RD
Mailing Address - Street 2:WYTHEVILLE CBOC
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382
Mailing Address - Country:US
Mailing Address - Phone:276-223-5449
Mailing Address - Fax:276-223-5455
Practice Address - Street 1:WYTHEVILLE CBOC
Practice Address - Street 2:100 PEPPERS FERRY RD
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24243-3121
Practice Address - Country:US
Practice Address - Phone:540-674-1377
Practice Address - Fax:540-674-1351
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904007099104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1144456161Medicaid