Healthcare Provider Details

I. General information

NPI: 1649407479
Provider Name (Legal Business Name): NICHOLAS S BRANOCK LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 06/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 DAVIS ST
EVANSTON IL
60201-4488
US

IV. Provider business mailing address

5600 N SHERIDAN RD APT 14B
CHICAGO IL
60660-4828
US

V. Phone/Fax

Practice location:
  • Phone: 847-220-2527
  • Fax: 847-570-1405
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149012784
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: