Provider Demographics
NPI:1194170191
Name:KOSA, MICHELLE L (MSW, LGSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:KOSA
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 GREAT TEAYS BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9815
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-201-5019
Practice Address - Street 1:97 GREAT TEAYS BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:SCOTT DEPOT
Practice Address - State:WV
Practice Address - Zip Code:25560-9815
Practice Address - Country:US
Practice Address - Phone:304-757-6999
Practice Address - Fax:304-201-5019
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00941890104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1194170191Medicaid