Provider Demographics
NPI:1841681863
Name:KOUGH, NICOLE
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:KOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:EDMONDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1012 N IDLER LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246-2703
Mailing Address - Country:US
Mailing Address - Phone:618-803-9678
Mailing Address - Fax:
Practice Address - Street 1:1121 N 6TH ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1219
Practice Address - Country:US
Practice Address - Phone:618-283-2222
Practice Address - Fax:844-270-4161
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL180.010758101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health