Provider Demographics
NPI:1255357802
Name:CAVENDISH, NICOLENE (EDD)
Entity type:Individual
Prefix:
First Name:NICOLENE
Middle Name:
Last Name:CAVENDISH
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 VAN VOORHIS RD
Mailing Address - Street 2:SUITE 28
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3453
Mailing Address - Country:US
Mailing Address - Phone:304-598-2971
Mailing Address - Fax:304-598-2975
Practice Address - Street 1:1137 VAN VOORHIS RD
Practice Address - Street 2:SUITE 28
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3453
Practice Address - Country:US
Practice Address - Phone:304-598-2971
Practice Address - Fax:304-598-2975
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV659103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0164951000Medicaid