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General NPI Number Information
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NPI Number | 1245181379
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Entity Type | Organization
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Legal Business Name | NICOLE DOUGLAS PSYCHOLOGY AND WELLNESS, PLLC
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Dates
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Enumeration Date | 02/05/2026
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Last Update Date | 02/05/2026
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Provider Practice Location Address
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Address Line | 3412 S ILLINOIS AVE
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City | CARBONDALE
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State | IL
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Zip | 62903-8362
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Country | US
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Telephone | 618-506-0107
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Fax | 618-457-8844
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Provider Business Mailing Address
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Address Line | 202 EXCALIBUR DR
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City | CARTERVILLE
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State | IL
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Zip | 62918-3602
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Country | US
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Telephone | 315-447-5432
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Fax |
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | NICOLE DOUGLAS
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Credential | PSYD
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Telephone | 315-447-5432
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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