Provider Demographics
NPI:1699484014
Name:KISAMORE, COURTNEY DANIELLE (LGSW)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:DANIELLE
Last Name:KISAMORE
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PEMBROKE CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-6404
Mailing Address - Country:US
Mailing Address - Phone:724-396-1510
Mailing Address - Fax:724-972-4627
Practice Address - Street 1:6510 MALL RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26501-8525
Practice Address - Country:US
Practice Address - Phone:304-557-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00946369104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1699484014Medicaid