Provider Demographics
NPI:1699306332
Name:MCNICHOLS, KELSEY (MHP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:MCNICHOLS
Suffix:
Gender:F
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6667 POWERS CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-6029
Mailing Address - Country:US
Mailing Address - Phone:618-645-2028
Mailing Address - Fax:
Practice Address - Street 1:206 W 5TH ST
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-1810
Practice Address - Country:US
Practice Address - Phone:618-524-9368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL101Y00000XMedicaid
IL101Y00000XOtherANY OTHER