Provider Demographics
NPI:1669197216
Name:KNICELY, PATRICK
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:KNICELY
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 1:2343 STALLION CIR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-6119
Mailing Address - Country:US
Mailing Address - Phone:540-315-2111
Mailing Address - Fax:
Practice Address - Street 1:901 N GLEBE RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1853
Practice Address - Country:US
Practice Address - Phone:323-205-7088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701014036101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional