MEDICARE: MRS. NICOLLE ALODIA MOLINA OSEQUEDA LICENSED MARRIAGE &

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	IMF 55828	CA
2	106H00000X	Marriage & Family Therapist	166000873	IL
3	106H00000X	Marriage & Family Therapist	50936	CA

General Provider Information

NPI Number	:	1437331428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLLE ALODIA MOLINA OSEQUEDA LICENSED MARRIAGE &

Provider Business Mailing Address
First Line	:	2755 N. PINE GROVE AVE.
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614
Country	:	US
Telephone Number	:	312-259-2665
Fax Number	:	773-248-3701

Provider Business Practice Location Address
First Line	:	2755 N. PINE GROVE AVE.
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614
Country	:	US
Telephone Number	:	312-259-2665
Fax Number	:	773-248-3701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2007
Last Update Date	:	08/30/2012

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