Provider Demographics
NPI:1457599490
Name:WELLER, NICOLE M (LCPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:WELLER
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 1:550 LANDMARKS BLVD
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-6321
Mailing Address - Country:US
Mailing Address - Phone:618-463-5905
Mailing Address - Fax:618-463-5935
Practice Address - Street 1:550 LANDMARKS BLVD
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6321
Practice Address - Country:US
Practice Address - Phone:618-463-5905
Practice Address - Fax:618-463-5935
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-006953101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional