Healthcare Provider Details

I. General information

NPI: 1538095229
Provider Name (Legal Business Name): NICOLE CAVALLO PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E WACKER DR STE 2300
CHICAGO IL
60601-1904
US

IV. Provider business mailing address

415 W FULLERTON PKWY APT 202
CHICAGO IL
60614-2828
US

V. Phone/Fax

Practice location:
  • Phone: 312-210-0089
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.023576
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: