Healthcare Provider Details

I. General information

NPI: 1962832550
Provider Name (Legal Business Name): CORY NIETZKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2013
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5547 N RAVENSWOOD AVE
CHICAGO IL
60640-1125
US

IV. Provider business mailing address

5547 N RAVENSWOOD AVE
CHICAGO IL
60640-1125
US

V. Phone/Fax

Practice location:
  • Phone: 773-818-0495
  • Fax: 773-769-1476
Mailing address:
  • Phone: 773-818-0495
  • Fax: 773-769-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0178.005724
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: