Provider Demographics
NPI:1992956619
Name:O'DEA, NICOLE SUZANNE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:SUZANNE
Last Name:O'DEA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2028 N SEMINARY AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-2626
Mailing Address - Country:US
Mailing Address - Phone:815-338-3590
Mailing Address - Fax:815-337-4406
Practice Address - Street 1:2028 N SEMINARY AVE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-2626
Practice Address - Country:US
Practice Address - Phone:815-338-3590
Practice Address - Fax:815-337-4406
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490146881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical