Healthcare Provider Details

I. General information

NPI: 1063174951
Provider Name (Legal Business Name): RUTH SHANIKA NATHANIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2021
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 W JACKSON BLVD STE 1201
CHICAGO IL
60604-4192
US

IV. Provider business mailing address

13139 PENNSYLVANIA CIR
THORNTON CO
80241-1726
US

V. Phone/Fax

Practice location:
  • Phone: 312-772-9796
  • Fax:
Mailing address:
  • Phone: 773-328-9810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178.015866
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: