Provider Demographics
NPI:1013476373
Name:MEJSTRIK, NICOLE (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MEJSTRIK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 183RD ST
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2633
Mailing Address - Country:US
Mailing Address - Phone:708-466-3454
Mailing Address - Fax:
Practice Address - Street 1:1361 E LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2153
Practice Address - Country:US
Practice Address - Phone:815-462-4273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-17
Last Update Date:2019-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008113101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional