Provider Demographics
NPI:1346796257
Name:ICE, GREGORY (LICSW)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:ICE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 GRAFTON RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508
Mailing Address - Country:US
Mailing Address - Phone:304-906-7791
Mailing Address - Fax:
Practice Address - Street 1:1627 GRAFTON RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508
Practice Address - Country:US
Practice Address - Phone:304-906-7791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP029417201041C0700X
FLSW105901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical