Healthcare Provider Details

I. General information

NPI: 1669336822
Provider Name (Legal Business Name): YOLANA NICHOLS LCMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 LINCOLN ST
GARY IN
46408-4453
US

IV. Provider business mailing address

4815 LINCOLN ST
GARY IN
46408-4453
US

V. Phone/Fax

Practice location:
  • Phone: 219-999-2405
  • Fax:
Mailing address:
  • Phone: 219-999-2405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227023524
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT22508636
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: