MEDICARE: MS. JULIE T NICKELS OTR

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	225XP0200X	Pediatric Occupational Therapist	056.006142	IL

General Provider Information

NPI Number	:	1578630059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JULIE T NICKELS OTR

Provider Business Mailing Address
First Line	:	2325 W HURON ST # 2
Second Line	:	CHICAGO
City	:	CHICAGO
State	:	IL
Zip	:	60612-1205
Country	:	US
Telephone Number	:	773-562-8345
Fax Number	:

Provider Business Practice Location Address
First Line	:	2325 W HURON ST # 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-1205
Country	:	US
Telephone Number	:	773-562-8345
Fax Number	:

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	05/09/2011

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