Provider Demographics
NPI:1558068676
Name:NICHOLAS, JUSTINE NICOLE
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:NICOLE
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:NICOLE
Other - Last Name:NICHOLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:268 JOHNSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:RICHWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26261-1314
Mailing Address - Country:US
Mailing Address - Phone:304-559-1531
Mailing Address - Fax:
Practice Address - Street 1:131 WELLNESS DR
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-5402
Practice Address - Country:US
Practice Address - Phone:888-736-3229
Practice Address - Fax:304-872-5415
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP009464671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical