Healthcare Provider Details

I. General information

NPI: 1033766886
Provider Name (Legal Business Name): MICHELLE NUCUP LCPC, CADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 W WILSON AVE
CHICAGO IL
60640-8090
US

IV. Provider business mailing address

845 W WILSON AVE
CHICAGO IL
60640-8090
US

V. Phone/Fax

Practice location:
  • Phone: 773-506-4283
  • Fax: 773-506-4847
Mailing address:
  • Phone: 773-506-4283
  • Fax: 773-506-4847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.012421
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: