Healthcare Provider Details

I. General information

NPI: 1073102877
Provider Name (Legal Business Name): NICOLE MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE SCHAEFFER

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 CARLYLE AVE STE 543
BELLEVILLE IL
62221-4558
US

IV. Provider business mailing address

1624 CARLYLE AVE STE 543
BELLEVILLE IL
62221-4558
US

V. Phone/Fax

Practice location:
  • Phone: 618-731-6923
  • Fax:
Mailing address:
  • Phone: 618-731-6923
  • Fax: 618-416-1252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.015247
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: