MEDICARE: NICOLE SCHAEFFER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	178.016448	IL

General Provider Information

NPI Number	:	1073102877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE SCHAEFFER

Provider Business Mailing Address
First Line	:	4114 N WATER TOWER PL STE F
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-6548
Country	:	US
Telephone Number	:	618-315-8470
Fax Number	:	618-216-1492

Provider Business Practice Location Address
First Line	:	4114 N WATER TOWER PL STE F
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-6548
Country	:	US
Telephone Number	:	618-634-7753
Fax Number	:	618-316-7058

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2021
Last Update Date	:	01/15/2021

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Directions to “ NICOLE SCHAEFFER ” Practice Location

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