Provider Demographics
NPI:1023489853
Name:PING TICKNOR, NICOLE (LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PING TICKNOR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:TICKNOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:433 S. PHELPS AVE.
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108
Mailing Address - Country:US
Mailing Address - Phone:815-397-4287
Mailing Address - Fax:815-397-3136
Practice Address - Street 1:433 S. PHELPS AVE.
Practice Address - Street 2:SUITE 2
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108
Practice Address - Country:US
Practice Address - Phone:815-397-4287
Practice Address - Fax:815-397-3136
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.009354101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional