Provider Demographics
NPI:1942764964
Name:ROED, NICHOLE (LCPC)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:ROED
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 1:914 SHABBONA ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-2427
Mailing Address - Country:US
Mailing Address - Phone:815-931-3922
Mailing Address - Fax:
Practice Address - Street 1:1802 N DIVISION ST STE 509
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-3107
Practice Address - Country:US
Practice Address - Phone:815-941-3882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012904101YM0800X
IL180013553101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health