Healthcare Provider Details

I. General information

NPI: 1023258449
Provider Name (Legal Business Name): NICOLE ROMANA CLARIZIO LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE KOSTAKEN

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 KINGERY HWY STE 102
WILLOWBROOK IL
60527-2250
US

IV. Provider business mailing address

139 N WILMETTE AVE
WESTMONT IL
60559-1730
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-1500
  • Fax:
Mailing address:
  • Phone: 630-567-0516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178005304
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180007600
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: