MEDICARE: DR. NICOLE FORD LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180009435	IL

General Provider Information

NPI Number	:	1306263702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE FORD LCPC

Provider Business Mailing Address
First Line	:	PO BOX 4793
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60680-4793
Country	:	US
Telephone Number	:	312-622-8615
Fax Number	:

Provider Business Practice Location Address
First Line	:	6227 S COTTAGE GROVE AVE
Second Line	:	310
City	:	CHICAGO
State	:	IL
Zip	:	60637-3176
Country	:	US
Telephone Number	:	312-622-8615
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2014
Last Update Date	:	10/25/2015

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