Provider Demographics
NPI:1972645059
Name:EARLES, ELIZABETH M (MAMAMSW)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:M
Last Name:EARLES
Suffix:
Gender:F
Credentials:MAMAMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MORRIS ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1842
Mailing Address - Country:US
Mailing Address - Phone:303-343-1022
Mailing Address - Fax:304-343-1025
Practice Address - Street 1:415 MORRIS ST
Practice Address - Street 2:SUITE 306
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1842
Practice Address - Country:US
Practice Address - Phone:303-343-1022
Practice Address - Fax:304-343-1025
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV453101YM0800X
WVCP004540231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001720450OtherBLUE CROSS/BLUE SHEILD