Provider Demographics
NPI:1912399064
Name:FEDELE, NICHOLAS (LCPC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:FEDELE
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27W130 ROOSEVELT RD STE 203
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1643
Mailing Address - Country:US
Mailing Address - Phone:630-588-8490
Mailing Address - Fax:630-588-8491
Practice Address - Street 1:27W130 ROOSEVELT RD STE 203
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1643
Practice Address - Country:US
Practice Address - Phone:630-588-8490
Practice Address - Fax:630-588-8491
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178010043101YP2500X
IL180009484101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1144352626OtherGROUP NPI