Healthcare Provider Details

I. General information

NPI: 1316285869
Provider Name (Legal Business Name): DBA- NICOLETTE KOMIE AND ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2912 NORWAY PINE LN
NORTHBROOK IL
60062-6425
US

IV. Provider business mailing address

2912 NORWAY PINE LANE
NORTHBROOK IL
60062-0002
US

V. Phone/Fax

Practice location:
  • Phone: 847-275-4115
  • Fax:
Mailing address:
  • Phone: 847-275-4115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. NIKKI KOMIE
Title or Position: DEVELOPMENTAL THERAPIST
Credential: M.D.
Phone: 847-275-4115