Healthcare Provider Details

I. General information

NPI: 1023650892
Provider Name (Legal Business Name): MRS. NICOLLE DANIELLE SHERWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2019
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3716 W BRIGHTON AVE
PEORIA IL
61615-2938
US

IV. Provider business mailing address

3716 W BRIGHTON AVE
PEORIA IL
61615-2938
US

V. Phone/Fax

Practice location:
  • Phone: 309-692-7755
  • Fax: 309-692-2262
Mailing address:
  • Phone: 309-692-7755
  • Fax: 309-692-2262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178023085
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: