MEDICARE: NICOLE TAYLOR PREETORIUS

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	103K00000X	Behavior Analyst		IL

General Provider Information

NPI Number	:	1629876271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE TAYLOR PREETORIUS

Provider Business Mailing Address
First Line	:	1952 W 21ST PL # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-4202
Country	:	US
Telephone Number	:	312-771-7065
Fax Number	:

Provider Business Practice Location Address
First Line	:	1952 W 21ST PL # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-4202
Country	:	US
Telephone Number	:	312-771-7065
Fax Number	:

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

Provider Enumeration Date	:	03/07/2025
Last Update Date	:	03/07/2025

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Directions to “ NICOLE TAYLOR PREETORIUS ” Practice Location

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