Provider Demographics
NPI:1538490172
Name:MCNICHOLL, STACI LEE (LCSW)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:LEE
Last Name:MCNICHOLL
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 1:201 W SPRINGFIELD AVE STE 1201
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-6385
Mailing Address - Country:US
Mailing Address - Phone:217-722-9079
Mailing Address - Fax:217-501-4322
Practice Address - Street 1:201 W SPRINGFIELD AVE STE 1201
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-6385
Practice Address - Country:US
Practice Address - Phone:217-722-9079
Practice Address - Fax:217-501-4322
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490101731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1538490172Medicaid