Provider Demographics
NPI:1669676607
Name:SIVA, NICOLE JANE (LSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:JANE
Last Name:SIVA
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 VALLEY COURT
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241
Mailing Address - Country:US
Mailing Address - Phone:304-636-3853
Mailing Address - Fax:
Practice Address - Street 1:971 HARRISON AVE
Practice Address - Street 2:YOUTH HEALTH SERVICE
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241
Practice Address - Country:US
Practice Address - Phone:304-636-9450
Practice Address - Fax:304-636-7057
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP00942414171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0023397001Medicaid