Healthcare Provider Details

I. General information

NPI: 1629491261
Provider Name (Legal Business Name): NICOLE KIOUSSIS LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 SLAWIN CT
MOUNT PROSPECT IL
60056-2183
US

IV. Provider business mailing address

8727 BELDEN AVE
RIVER GROVE IL
60171-1825
US

V. Phone/Fax

Practice location:
  • Phone: 312-730-0361
  • Fax: 224-999-7566
Mailing address:
  • Phone: 312-730-0361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number00117978
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.009689
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.011702
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: