Basic Information
| Provider Information | |||||||||
| NPI: | 1790754331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICELY | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4841 MONROE ST | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436234385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193526666 | ||||||||
| FaxNumber: | 4193531117 | ||||||||
| Practice Location | |||||||||
| Address1: | 970 W WOOSTER ST | ||||||||
| Address2: | STE. 124 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434022643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193526666 | ||||||||
| FaxNumber: | 4193531117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 01/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 4016 | OH | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0698099 | 05 | OH | MEDICAID |