Healthcare Provider Details

I. General information

NPI: 1295319416
Provider Name (Legal Business Name): MS. TAYLOR NICOLE VACA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 HIGHLAND AVE
OAK PARK IL
60304-2243
US

IV. Provider business mailing address

541 TERRACE LN
SOUTH ELGIN IL
60177-2254
US

V. Phone/Fax

Practice location:
  • Phone: 773-413-8447
  • Fax:
Mailing address:
  • Phone: 847-532-4435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: