Healthcare Provider Details

I. General information

NPI: 1194149542
Provider Name (Legal Business Name): NICASA, NFP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 1ST ST
HIGHLAND PARK IL
60035-3202
US

IV. Provider business mailing address

31979 N FISH LAKE RD
ROUND LAKE IL
60073-9517
US

V. Phone/Fax

Practice location:
  • Phone: 847-433-1303
  • Fax: 847-546-6760
Mailing address:
  • Phone: 847-546-6450
  • Fax: 847-546-6760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberA-0614-0006
License Number StateIL

VIII. Authorized Official

Name: LINDA SNELTEN
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 847-546-6450