=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275776882
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE M BAILEY LCPC, ATR, CADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2009
-----------------------------------------------------
Last Update Date | 04/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 633 ROGERS ST SUITE 111
-----------------------------------------------------
City | DOWNERS GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-623-3260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1115 N ROCKWELL ST APT 3
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-623-3260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180007162
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------