=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942764964
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLE ROED LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2019
-----------------------------------------------------
Last Update Date | 01/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1802 N DIVISION ST STE 509
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-3107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-941-3882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 914 SHABBONA ST
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-2427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-931-3922
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 178.012904
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180013553
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------