Provider Demographics
NPI:1184901035
Name:DAVID, WILLIE NICK
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:NICK
Last Name:DAVID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:KWETHLUK
Mailing Address - State:AK
Mailing Address - Zip Code:99621
Mailing Address - Country:US
Mailing Address - Phone:907-757-6627
Mailing Address - Fax:907-757-6626
Practice Address - Street 1:49 AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:KWETHLUK
Practice Address - State:AK
Practice Address - Zip Code:99621
Practice Address - Country:US
Practice Address - Phone:907-757-6627
Practice Address - Fax:907-757-6626
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid