Provider Demographics
NPI:1790754331
Name:NICELY, ERIC RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:RICHARD
Last Name:NICELY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4841 MONROE ST
Mailing Address - Street 2:STE. 100
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4385
Mailing Address - Country:US
Mailing Address - Phone:419-352-6666
Mailing Address - Fax:419-353-1117
Practice Address - Street 1:970 W WOOSTER ST
Practice Address - Street 2:STE. 124
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2643
Practice Address - Country:US
Practice Address - Phone:419-352-6666
Practice Address - Fax:419-353-1117
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4016103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0698099Medicaid
OH0698099Medicaid