Provider Demographics
NPI:1316604200
Name:CANTERBURY, JULIE
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:CANTERBURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1256
Mailing Address - Country:US
Mailing Address - Phone:304-574-4220
Mailing Address - Fax:
Practice Address - Street 1:100 N COURT ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1200
Practice Address - Country:US
Practice Address - Phone:304-574-4229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-26
Last Update Date:2023-04-04
Deactivation Date:2023-01-10
Deactivation Code:
Reactivation Date:2023-01-17
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
WV22-9153175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant