Healthcare Provider Details

I. General information

NPI: 1053041970
Provider Name (Legal Business Name): NICOLE L TOWNSEND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 N BROADWAY ST
CHICAGO IL
60613-4567
US

IV. Provider business mailing address

5531 N ARTESIAN AVE APT 3
CHICAGO IL
60625-7966
US

V. Phone/Fax

Practice location:
  • Phone: 773-496-4433
  • Fax:
Mailing address:
  • Phone: 248-910-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: