Provider Demographics
NPI:1114792140
Name:FRALIC, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:FRALIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:FRALIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:20 WATERSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:ONA
Mailing Address - State:WV
Mailing Address - Zip Code:25545-1149
Mailing Address - Country:US
Mailing Address - Phone:681-888-1331
Mailing Address - Fax:
Practice Address - Street 1:1206 QUARRIER ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1843
Practice Address - Country:US
Practice Address - Phone:304-513-3900
Practice Address - Fax:304-988-4424
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health