Healthcare Provider Details

I. General information

NPI: 1417015298
Provider Name (Legal Business Name): BRUCE EDWARD NICELY NCSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 E HUDSON ST
COLUMBUS OH
43211-1034
US

IV. Provider business mailing address

6949 COOK RD
POWELL OH
43065-8970
US

V. Phone/Fax

Practice location:
  • Phone: 614-365-5220
  • Fax:
Mailing address:
  • Phone: 614-365-5220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: