Healthcare Provider Details

I. General information

NPI: 1194552752
Provider Name (Legal Business Name): NICOLE MARIE GARCIA PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 STATION DR STE 300
CRYSTAL LAKE IL
60014-8003
US

IV. Provider business mailing address

360 STATION DR STE 300
CRYSTAL LAKE IL
60014-8003
US

V. Phone/Fax

Practice location:
  • Phone: 815-455-1800
  • Fax: 815-455-1875
Mailing address:
  • Phone: 815-455-1800
  • Fax: 815-455-1875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.011296
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071011296
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: