Provider Demographics
NPI:1578001095
Name:CRISSEY, NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CRISSEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5230 6TH STREET FRONTAGE RD E
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5128
Mailing Address - Country:US
Mailing Address - Phone:217-585-1180
Mailing Address - Fax:217-585-4747
Practice Address - Street 1:5230 6TH STREET FRONTAGE RD E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5128
Practice Address - Country:US
Practice Address - Phone:217-585-1180
Practice Address - Fax:217-585-4747
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490171571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1490171157OtherLICENSED CLINICAL SOCIAL WORKER