Healthcare Provider Details

I. General information

NPI: 1881306595
Provider Name (Legal Business Name): RAYLINN G. NUCKOLLS LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 N SHERIDAN RD
CHICAGO IL
60613-2010
US

IV. Provider business mailing address

4025 N SHERIDAN RD
CHICAGO IL
60613-2010
US

V. Phone/Fax

Practice location:
  • Phone: 773-388-1600
  • Fax:
Mailing address:
  • Phone: 773-388-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150109359
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: