Healthcare Provider Details

I. General information

NPI: 1194480392
Provider Name (Legal Business Name): NICOLE MCKENZIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 11/26/2021
Certification Date: 11/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9115 S CICERO AVE STE 200
OAK LAWN IL
60453-1771
US

IV. Provider business mailing address

14840 SHEPARD DR
DOLTON IL
60419-2467
US

V. Phone/Fax

Practice location:
  • Phone: 773-449-0859
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: