Provider Demographics
NPI:1659473437
Name:KELLEY, NICOLE ANGELA (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANGELA
Last Name:KELLEY
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 1:702 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:IL
Mailing Address - Zip Code:61748-9476
Mailing Address - Country:US
Mailing Address - Phone:309-242-7925
Mailing Address - Fax:
Practice Address - Street 1:112 BOEYKENS PL
Practice Address - Street 2:SUITE 4A
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2152
Practice Address - Country:US
Practice Address - Phone:309-242-7925
Practice Address - Fax:309-454-9521
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490114001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical