Healthcare Provider Details

I. General information

NPI: 1205532108
Provider Name (Legal Business Name): NICOLE B KOWALCZYK LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2023
Last Update Date: 02/01/2023
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 OAK BLUFF TER
UTICA IL
61373-9509
US

IV. Provider business mailing address

33 OAK BLUFF TER
UTICA IL
61373-9509
US

V. Phone/Fax

Practice location:
  • Phone: 815-780-0769
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.012824
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: