Provider Demographics
NPI:1649287830
Name:NICHOLSON, STELLA MAE (LCPC)
Entity type:Individual
Prefix:MS
First Name:STELLA
Middle Name:MAE
Last Name:NICHOLSON
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 1:2200 S. MAIN ST.
Mailing Address - Street 2:SUITE 309
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148
Mailing Address - Country:US
Mailing Address - Phone:630-620-5100
Mailing Address - Fax:815-248-9295
Practice Address - Street 1:2200 S MAIN ST
Practice Address - Street 2:SUITE 309
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-5334
Practice Address - Country:US
Practice Address - Phone:630-620-5100
Practice Address - Fax:815-248-9295
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional