Provider Demographics
NPI:1144766908
Name:THEISS, NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:THEISS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:HOULTZHOUSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-0101
Mailing Address - Country:US
Mailing Address - Phone:618-248-2040
Mailing Address - Fax:618-248-2040
Practice Address - Street 1:40B EDWARDSVILLE PROF PARK
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3602
Practice Address - Country:US
Practice Address - Phone:618-248-2040
Practice Address - Fax:618-248-2040
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.010261101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional