MEDICARE: DR. NICOLE JUSTINE MASSEY-HASTINGS PSYD, LCP

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	101YM0800X	Mental Health Counselor	180.008385	IL
2	103TC0700X	Clinical Psychologist	071008745	IL

General Provider Information

NPI Number	:	1609174192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE JUSTINE MASSEY-HASTINGS PSYD, LCP

Provider Business Mailing Address
First Line	:	15 SPINNING WHEEL RD STE 116
Second Line	:
City	:	HINSDALE
State	:	IL
Zip	:	60521-2983
Country	:	US
Telephone Number	:	630-708-0362
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 SPINNING WHEEL RD STE 116
Second Line	:
City	:	HINSDALE
State	:	IL
Zip	:	60521-2983
Country	:	US
Telephone Number	:	630-708-0362
Fax Number	:

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

Provider Enumeration Date	:	03/07/2011
Last Update Date	:	09/08/2021

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