Healthcare Provider Details

I. General information

NPI: 1407534324
Provider Name (Legal Business Name): NICOLE KAREN ROSE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CENTRAL AVE STE 250
NORTHFIELD IL
60093-3024
US

IV. Provider business mailing address

400 CENTRAL AVE STE 250
NORTHFIELD IL
60093-3024
US

V. Phone/Fax

Practice location:
  • Phone: 773-817-2306
  • Fax:
Mailing address:
  • Phone: 773-817-2306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.010816
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: