Individual ProviderNicole TheissCounselorBehavioral Health & Social Service ProvidersPractice Address40b Edwardsville Prof Park, Edwardsville, IL 62025-3602(618) 248-2040PECOS EnrollmentBased on the most recent information from CMS, provider Nicole Theiss does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 5 days ago.Profile DetailsProvider ID1144766908Provider TypeIndividualFull NameTheiss, NicoleCredentialMAGenderFemaleSole ProprietorYesEnumeration Date1/17/2017Last Updated1/17/2017Contact InformationPractice LocationPractice Address40b Edwardsville Prof Park, Edwardsville, IL 62025-3602Phone(618) 248-2040Fax(618) 248-2040Mailing LocationMailing AddressPO Box 101, Edwardsville, IL 62025-0101Phone(618) 248-2040Fax(618) 248-2040Provider TaxonomiesCodeDescriptionLicenseCode101YP2500XPrimaryDescriptionCounselorBehavioral Health & Social Service ProvidersLicense178.010261Illinois