Healthcare Provider Details

I. General information

NPI: 1356993406
Provider Name (Legal Business Name): NICOLE COSSU PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 12/29/2019
Certification Date: 12/29/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N MICHIGAN AVE STE 1400
CHICAGO IL
60601-4011
US

IV. Provider business mailing address

1610 N WHIPPLE ST APT 3
CHICAGO IL
60647-5081
US

V. Phone/Fax

Practice location:
  • Phone: 312-815-9660
  • Fax:
Mailing address:
  • Phone: 347-221-7631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178009553
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071010135
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: