=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275066094
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH A KLICKER-NICKLAY LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2017
-----------------------------------------------------
Last Update Date | 01/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1440 RENAISSANCE DR STE 320
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-1471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-236-7563
-----------------------------------------------------
Fax | 224-985-2119
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4128 N SHERIDAN RD APT G
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-236-7563
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180010949
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------