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General NPI Number Information
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NPI Number | 1134734221
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Entity Type | Individual
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Provider Name | NICOLE LYNN EKISS LCSW
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Gender | Female
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Dates
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Enumeration Date | 09/15/2020
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Last Update Date | 10/07/2020
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Provider Practice Location Address
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Address Line | 1170 E RIVERSIDE AVE
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City | DECATUR
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State | IL
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Zip | 62521-3566
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Country | US
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Telephone | 217-387-3625
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Fax |
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Provider Business Mailing Address
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Address Line | 1615 RIDGEWOOD CT
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City | MOUNT ZION
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State | IL
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Zip | 62549-1136
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Country | US
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Telephone | 217-853-4410
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.022447
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License Number State | IL
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