Healthcare Provider Details

I. General information

NPI: 1427880210
Provider Name (Legal Business Name): NICOLE WICKS MA, LPC
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6440 N CENTRAL AVE
CHICAGO IL
60646-2935
US

IV. Provider business mailing address

6440 N CENTRAL AVE
CHICAGO IL
60646-2935
US

V. Phone/Fax

Practice location:
  • Phone: 773-840-1220
  • Fax:
Mailing address:
  • Phone: 773-840-1220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.021518
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.021518
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: