Provider Demographics
NPI:1316097538
Name:SMITH, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SMITH
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:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-0176
Mailing Address - Country:US
Mailing Address - Phone:304-792-7130
Mailing Address - Fax:304-792-7146
Practice Address - Street 1:RT. 10 THREE MILE CURVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-9998
Practice Address - Country:US
Practice Address - Phone:304-792-7130
Practice Address - Fax:304-792-7146
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV923103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005460001Medicaid
WV0005460002Medicaid
WV3810011604Medicaid
WV0005460000Medicaid