Provider Demographics
NPI:1144832528
Name:PRINCETON PSYCHOLOGICAL LLC
Entity type:Organization
Organization Name:PRINCETON PSYCHOLOGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:CECIL
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:304-308-3819
Mailing Address - Street 1:PO BOX 5509
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-5509
Mailing Address - Country:US
Mailing Address - Phone:304-308-3819
Mailing Address - Fax:
Practice Address - Street 1:321 ROGERS ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-3639
Practice Address - Country:US
Practice Address - Phone:304-308-3819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1063067882Medicaid