Provider Demographics
NPI:1780852160
Name:NICELY, CHARLEENE VIRGINIA (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLEENE
Middle Name:VIRGINIA
Last Name:NICELY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CHARLEENE
Other - Middle Name:NICELY
Other - Last Name:GALLENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:555 LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28792
Mailing Address - Country:US
Mailing Address - Phone:828-778-4721
Mailing Address - Fax:
Practice Address - Street 1:2270 HENDERSONVILLE RD
Practice Address - Street 2:STE 1
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-2734
Practice Address - Country:US
Practice Address - Phone:828-778-4721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-19
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAD003667101YA0400X
NCLCAS 1142103TA0400X, 103TA0400X
NC0893103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical