Provider Demographics
NPI:1730391962
Name:SPERRY, BRIANNE MICHELLE (LICSW)
Entity type:Individual
Prefix:
First Name:BRIANNE
Middle Name:MICHELLE
Last Name:SPERRY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-0176
Mailing Address - Country:US
Mailing Address - Phone:304-792-7130
Mailing Address - Fax:304-896-5184
Practice Address - Street 1:174 LMAH CENTER RD
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-4058
Practice Address - Country:US
Practice Address - Phone:304-792-7130
Practice Address - Fax:304-896-5184
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WVBP00944055104100000X
WVDP009440551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVBP00944055OtherWV BOARD OF SOCIAL WORK
WVDP00944055OtherWV BOARD OF SOCIAL WORK