Healthcare Provider Details

I. General information

NPI: 1235526096
Provider Name (Legal Business Name): NICOLE R WILDROUDT LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4104 SPRINGMILL DR
KOKOMO IN
46902-5168
US

IV. Provider business mailing address

4104 SPRINGMILL DR
KOKOMO IN
46902-5168
US

V. Phone/Fax

Practice location:
  • Phone: 937-554-3667
  • Fax:
Mailing address:
  • Phone: 937-554-3667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number86000458A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-24135
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2606445
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.162012
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: