MEDICARE: MRS. NICOLE L VANDERVOORT M.A. CCC

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	235Z00000X	Speech-Language Pathologist	146000845	IL

General Provider Information

NPI Number	:	1528305398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE L VANDERVOORT M.A. CCC

Provider Business Mailing Address
First Line	:	2043 N HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4369
Country	:	US
Telephone Number	:	312-266-8133
Fax Number	:	773-528-0013

Provider Business Practice Location Address
First Line	:	2043 N HALSTED ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4369
Country	:	US
Telephone Number	:	312-266-8133
Fax Number	:	773-528-0013

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

Provider Enumeration Date	:	01/13/2013
Last Update Date	:	01/13/2013

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