Provider Demographics
NPI:1649686973
Name:TICE, DAVID (MS, LPC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:TICE
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-5524
Mailing Address - Country:US
Mailing Address - Phone:715-842-0944
Mailing Address - Fax:715-845-6477
Practice Address - Street 1:631 FOREST ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-5524
Practice Address - Country:US
Practice Address - Phone:715-842-0944
Practice Address - Fax:715-845-6477
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5350-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1649686973Medicaid