Provider Demographics
NPI:1093140253
Name:LIST, NICOLE ANNE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ANNE
Last Name:LIST
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1648
Mailing Address - Country:US
Mailing Address - Phone:217-854-3166
Mailing Address - Fax:217-854-9729
Practice Address - Street 1:320 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1648
Practice Address - Country:US
Practice Address - Phone:217-854-3166
Practice Address - Fax:217-854-9729
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178009320101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL178009320Medicaid