Healthcare Provider Details

I. General information

NPI: 1639688641
Provider Name (Legal Business Name): NICOLE LARUCCI, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PYOTT RD STE 201E
LAKE IN THE HILLS IL
60156-9797
US

IV. Provider business mailing address

208 S EMERALD DR
MCHENRY IL
60051-3309
US

V. Phone/Fax

Practice location:
  • Phone: 224-703-6504
  • Fax: 224-678-9652
Mailing address:
  • Phone: 630-338-3696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.008684
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: NICOLE LARUCCI
Title or Position: OWNER/PROVIDER
Credential: MA LCPC
Phone: 630-338-3696