Healthcare Provider Details

I. General information

NPI: 1669303293
Provider Name (Legal Business Name): NICOLE WATERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3933 W 105TH ST
CHICAGO IL
60655-3707
US

IV. Provider business mailing address

3933 W 105TH ST
CHICAGO IL
60655-3707
US

V. Phone/Fax

Practice location:
  • Phone: 708-476-0377
  • Fax:
Mailing address:
  • Phone: 708-476-0377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.041169
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: