Provider Demographics
NPI:1760579338
Name:NICELY, KAREN (LPC)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:NICELY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5268 GODWIN BLVD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8135
Mailing Address - Country:US
Mailing Address - Phone:757-925-2227
Mailing Address - Fax:
Practice Address - Street 1:5268 GODWIN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8135
Practice Address - Country:US
Practice Address - Phone:757-925-2227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA084-07-004101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5409098Medicaid
VA5409071Medicaid
VA5400635Medicaid