Healthcare Provider Details

I. General information

NPI: 1194040519
Provider Name (Legal Business Name): MARELISE NIEUWENHUIZEN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304-1227
US

IV. Provider business mailing address

3200 MACCORKLE AVE SE
CHARLESTON WV
25304-1227
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-1000
  • Fax: 304-388-1041
Mailing address:
  • Phone: 304-388-1000
  • Fax: 304-388-1041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0435120
License Number StateZZ
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4259699
License Number StateZZ
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25697
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: