Provider Demographics
NPI:1447717384
Name:BOSWELL, NICOLE EILEEN (MA, LPC, NCC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:EILEEN
Last Name:BOSWELL
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:PEDONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC, NCC
Mailing Address - Street 1:425 S ROOSEVELT AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3068
Mailing Address - Country:US
Mailing Address - Phone:815-341-2060
Mailing Address - Fax:
Practice Address - Street 1:13728 W CAREFREE DR
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-8655
Practice Address - Country:US
Practice Address - Phone:815-955-8728
Practice Address - Fax:708-966-4244
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.014593101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL178.014593OtherLICENSED PROFESSIONAL COUNSELOR