MEDICARE: DR. NICOLE SUZANNE SANFORD PSYD

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1760763197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE SUZANNE SANFORD PSYD

Provider Business Mailing Address
First Line	:	1 W SUPERIOR ST
Second Line	:	APT 4812
City	:	CHICAGO
State	:	IL
Zip	:	60654-8803
Country	:	US
Telephone Number	:	312-613-2947
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 W SUPERIOR ST
Second Line	:	APT 4812
City	:	CHICAGO
State	:	IL
Zip	:	60654-8803
Country	:	US
Telephone Number	:	312-613-2947
Fax Number	:

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

Provider Enumeration Date	:	08/30/2011
Last Update Date	:	06/24/2014

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