Healthcare Provider Details

I. General information

NPI: 1164521027
Provider Name (Legal Business Name): NIKKI M. LIVELY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 S MICHIGAN AVE SUITE 500
CHICAGO IL
60603-3357
US

IV. Provider business mailing address

8 S MICHIGAN AVE SUITE 500
CHICAGO IL
60603-3357
US

V. Phone/Fax

Practice location:
  • Phone: 847-733-4300
  • Fax: 847-733-0390
Mailing address:
  • Phone: 847-733-4300
  • Fax: 847-733-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149010124
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number149010124
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: