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General NPI Number Information
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NPI Number | 1285516641
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Entity Type | Individual
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Provider Name | GRACIE LEEANN MCNICOLL
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Gender | Female
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Dates
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Enumeration Date | 07/24/2025
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Last Update Date | 07/24/2025
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Provider Practice Location Address
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Address Line | 1003 N DAMEN AVE
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City | CHICAGO
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State | IL
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Zip | 60622-4391
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Country | US
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Telephone | 312-348-6288
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Fax |
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Provider Business Mailing Address
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Address Line | 509 W DEMING PL APT 2S
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City | CHICAGO
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State | IL
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Zip | 60614-5946
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Country | US
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Telephone | 406-291-9226
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 242.008512
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License Number State | IL
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