Provider Demographics
NPI:1700126067
Name:GENBAUER, NICOLE TERESA (LPC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:TERESA
Last Name:GENBAUER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:TERESA
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 NORTH SHORE DRIVE SUITE 120
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044
Mailing Address - Country:US
Mailing Address - Phone:847-615-1698
Mailing Address - Fax:847-615-1697
Practice Address - Street 1:900 NORTH SHORE DRIVE SUITE 120
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044
Practice Address - Country:US
Practice Address - Phone:847-615-1698
Practice Address - Fax:847-615-1697
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-25
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008491101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional