Provider Demographics
NPI:1205532108
Name:KOWALCZYK, NICOLE B (LCPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:B
Last Name:KOWALCZYK
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 1:33 OAK BLUFF TER
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:IL
Mailing Address - Zip Code:61373-9509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 OAK BLUFF TER
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:IL
Practice Address - Zip Code:61373-9509
Practice Address - Country:US
Practice Address - Phone:815-780-0769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012824101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional