Provider Demographics
NPI:1568221158
Name:WIESMAN, NICOLE MARIE (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:WIESMAN
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 1:21W250 AUDUBON RD
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5205
Mailing Address - Country:US
Mailing Address - Phone:309-242-2172
Mailing Address - Fax:
Practice Address - Street 1:21W250 AUDUBON RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5205
Practice Address - Country:US
Practice Address - Phone:309-242-2172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-15
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.015863101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health