Healthcare Provider Details

I. General information

NPI: 1679725634
Provider Name (Legal Business Name): KEN NICE MSW, LGSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 3RD ST
NEW MARTINSVILLE WV
26155-1403
US

IV. Provider business mailing address

761 3RD ST
NEW MARTINSVILLE WV
26155-1403
US

V. Phone/Fax

Practice location:
  • Phone: 304-455-3035
  • Fax:
Mailing address:
  • Phone: 304-455-3035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: