Provider Demographics
NPI:1912628579
Name:MEBUST, NICOLLETTE
Entity Type:Individual
Prefix:
First Name:NICOLLETTE
Middle Name:
Last Name:MEBUST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3904 MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:ISLAND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60042-9409
Mailing Address - Country:US
Mailing Address - Phone:847-528-8817
Mailing Address - Fax:
Practice Address - Street 1:820 E TERRA COTTA AVE STE 116
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3650
Practice Address - Country:US
Practice Address - Phone:224-256-2607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016491101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health