Provider Demographics
NPI:1336695337
Name:NICOLE WAHLERT, LLC
Entity Type:Organization
Organization Name:NICOLE WAHLERT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAHLERT
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, CADC
Authorized Official - Phone:847-323-4092
Mailing Address - Street 1:1500 SEQUOIA TRL
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-2019
Mailing Address - Country:US
Mailing Address - Phone:847-323-4092
Mailing Address - Fax:
Practice Address - Street 1:1500 SEQUOIA TRL
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-2019
Practice Address - Country:US
Practice Address - Phone:847-323-4092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19904101YA0400X
IL180005542101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty