Provider Demographics
NPI:1699249722
Name:NICKRENT, ELLEN M (LPC, NCC)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:NICKRENT
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11042 MANCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-1244
Mailing Address - Country:US
Mailing Address - Phone:844-462-3492
Mailing Address - Fax:
Practice Address - Street 1:11042 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-1244
Practice Address - Country:US
Practice Address - Phone:844-462-3492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011005978101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor