MEDICARE: MISS NICOLE LYNN MYERS LCPC

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	178.014880	IL
2	101YP2500X	Professional Counselor	180014597	IL

General Provider Information

NPI Number	:	1669037933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS NICOLE LYNN MYERS LCPC

Provider Business Mailing Address
First Line	:	555 S PERRYVILLE RD STE 222
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2527
Country	:	US
Telephone Number	:	815-331-1023
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 S PERRYVILLE RD STE 222
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2527
Country	:	US
Telephone Number	:	815-331-1023
Fax Number	:

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

Provider Enumeration Date	:	05/02/2019
Last Update Date	:	11/14/2024

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